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cbsrco <br /> MMIN ■,E. "ff <br /> December 20, 2004 <br /> San Joaquin County Environ. Health <br /> 304 E. Weber Street <br /> Stockton, CA 95202 <br /> Subject: Owner Statements of Designated Underground Storage Tank (UST) <br /> Operator and Understanding of and Compliance with UST Requirements <br /> Facility Name: TRACY Costco gas station <br /> Facility ID #: 658 <br /> Facility Address: 3250 W. Grantline Rd <br /> Tracy, CA, 95377 <br /> Facility Phone #: <br /> Designated UST Operator(s) for this facility (see attached list for alternates); <br /> Primary Designated Operator: Jackie Dougherty <br /> Business Name: Belshire Environmental Services, Inc. <br /> Designated Operator's Phone #: (949) 450-1010 <br /> Relation to UST Facility: Third Party <br /> International Code Council 5234433-UC <br /> Certification #: <br /> Expiration Date: 816/2006 <br /> 1 certify that, for the facility indicated at the top of this page, the individual(s) listed <br /> above will serve as Designated UST Operator(s). The individual(s) will conduct and <br /> document monthly facility inspections and annual facility employee training, in <br /> accordance with California Code of Regulations, Title 23, section 2715(c) - (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 OR OWNER'S AGENT: <br /> Dennis Bock <br /> Costco Compliance Manager <br /> SI TU RE OF TANK OWNER OR OWNER'S AGENT: <br /> a <br /> OWNER'S PHONE #: (425) 427-7653 <br /> Attached: Alternate Designated Operator List <br /> 999 Lake Drive • Issaquah, WA 98027 • 425/313-8100 • www.costco,com <br />