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t 2Ct13-07-29 16:02 Wells Fargo Bank 2094604395 >: 2094683433 P 1/2 <br /> RECEIVE <br /> 41, <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator JUL 9 2013 <br /> and Understanding of and Compliance with UST RequirementENVI RON MENTAL <br /> .FIE—CEI'ARTMENT <br /> FacilityNamc:VS-Okti 5 ovdrt Go- Facility ID#: <br /> Facility Address: 749 E Charter Way Reason for Submitting this Form(Check One) <br /> Stockton,CA.95206 Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnniz Relation to UST Facility(Check 0m) <br /> Business Name(lfd jTemntfrom above): D Owner Cl Operator ❑ Employee <br /> Designated operator's Phone 0:(209)518-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date;05/31/2015 <br /> ALTERNATE I O lural <br /> Dc%ignated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(IfdlIferentfromabove)t ❑ Owner ❑ Operator ❑ Employee <br /> Designated Oper'ator's Phone ft; 0 Service Technician ❑ Third-Patty <br /> 41memtuional Code Council Certification#; Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1fdyferentfrom above): ❑ Owner p Operator El Employee <br /> Designated Operator's Phone ft: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification N: 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 individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances) g <br /> applicable to underground stowage tanks. <br /> NAME OF TANK OWNER(Please Print): I r":11 1/,t(G��rf'if \4 �1 t t � Is) <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 07/29/13 OWNER'S PHONE#: 2,67 - <br /> NOTE: <br /> 67 NOTE: 1)SUBMIT THIS 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:yy w;tt.@CL2rd n i2w/_ust/contacycuna ngyjhtm1. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />