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Owner Statemen&f Designated Underground Sto* Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: COSTCO 1039 _ Facility ID: 1031 - Facility Address: 2440 DANIELS ST. Reason for Submitting this f=orm (Check One) MANTECA, CA 95336 ■ Change of Designated Operator Facility Phone#: 2098258200 ❑ Updated Certificate Expiration Date Designated UST © erator s for this Facili PRIMARY Designated Operator's Name: Jhustin Abeleda Relation to the UST Facility(Check One) Business Name(If different from above): Betshire Environmental Services, Inc. ❑ Owner ❑ Operator © Employee Designated Operator's Phone#_ (949)460-6200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8036229-UC Expiration Date: 9126/2011 ALTERNATE 1 _ Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(if different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician o Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup documont Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician 0 Third-Party International Code Council Certification#: referto backup document Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will - serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of /Regulations, title 23, section 2715(c) - (f). Furthermore, l understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. I Name of Tank Owner (print): Name of Tank Owner: Dennis Back Owner's Phone #: (425) 427-7653 ___.._.. Signature of Tank Owner: Date: if Owner's Phone #: I NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVVAILA13LE AT:wwwmaterboards.ca.gov/u sticontactslcupa_agys.htmI. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.