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Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> �FacilityID#' <br /> Facility Name: 76 <br /> Facility Adtlress:57a W.Crrnneliuc Rd for Submitting this Form(Check One) <br /> Tracy,CA.95376 R Change of Designated operator <br /> ❑ Update Certificate Expiration Date <br /> Facility Phone 0.(209)833-3416 <br /> Des nated UST Operator(s)for this Facili <br /> Egg <br /> Relation w UST Facility(Check 0�) <br /> rator's Name: Karen R Aruaiz <br /> (If dierent from above): ❑ 0`„trc ❑ Operator ❑ lrmployec <br /> rator's Phone#:(209)518-4$36 ❑ Servicc Technician X Third-Party <br /> de Council Certification#:5266643-IXC Expiration pate: 9/12/07 <br /> ALTERNATI%1 un <br /> Relation to UJ 1 Facility(Check One) <br /> Designated Operator's Name: <br /> Easiness Name(Xf d�erent%tom above): ❑ Owner Q Operator 11 )employee <br /> Designated Operator's Phone#: <br /> El Service Technician a Third-ratty <br /> Expiration.Date: <br /> International C'nde Council Certification#: <br /> ALTERNATE 2 (Opilonal) <br /> llevignatcd Operator's Name Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Deeignated Operator's Phone# ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: <br /> Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individuals)will conduct and duutuncnt monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(e) -(f)• <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Prin <br /> SIGNATURE OF TANK OWNER: <br /> DATE: _12/26106- <br /> OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT TMS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT- www.waterboards.ca, ov/usUcontacts/cu a n s.html. <br /> 2)NOTUFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITMN 30 DAYS <br /> OF THE CHANGE- <br /> November 2004 <br /> Te/T0 SJdd 000-d Sd9 ONO d 9L9L68863Z 6T :b0 903Z/9Z/ZT <br />