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Owner Staterneo of Designated Underground Sto4W Tank (UST) Operator and Understanding of and Compliance with UST Requirements [Facility Name: COSTCO 1031 Facility ID: 1031 Facility Address: 2440 DANIELS ST. Reason for Submitting this Form(Check One) MANTECA,CA 95336 5 Change of Designated Operator Facility Phone* 2098258200 0 Updated Cerdficate Expiration Date ............. Designated UST 012orator(s) for this Facility PRIMARY Designated Operator's Name: JhustinAMeda Relation to the UST Facility(Check One) Business Name(if different from above): Befshire Environmental Services, Inc. 0 Owner C3 Operator 0 Employee Designated Operators Phone* (949)460-5200 1 0 Service Technician 0 Third-Party International Code Council Certification 8036229-UC Expiration Date: 9126/2011 ALTERNATE ........... : 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 0 Owner 0 Operator 0 Employee Designated Operator's Phone* refer to backup document E3 Service Technician m Third-Party international Code Council Certification* refer to backup document Expiration Date-, refer to backup document ALTERNATE 2 Designated Operators Name: refer to backup document Relation to the LIST Facility(Check One) Business Name(If different from above): refer to backup document N Owner 0 Operator 0 Employee 11 Designated Operator's Phone#: refer to backup document Cl Service Technician a Third-Party Internaticnal Code Council Certification M refer to backup document Expiration Date: nsfisrto 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, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print). ................ Signature of Tank Owner: ............. Date: Owner'sPhone #: v. 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 AVAILABLE AT:www waterboards ca gov1usUcontacwcupa_&gys html 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE