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le 1 0 0 RECEIVE� Owner Statements of Designated Underground Storage Tank (UST) Op�6%; 2 2011 and Understanding of and Compliance with UST Requirements ENVIRONMENTAL HEALTH S Facility Name: COSTCO 0038 Facility ID: 0038 PERMIT/SERVIC Facility Address: 1616 EAST HAMMER LANE Reason for Submitting this Form (Check One) STOCKTON , CA 95210 ■ Change of Designated Operator O Updated Certificate Expiration Date _ Facility Phone M (209) 478.2040 Designated UST Operator(s) for this Facility PRIMARY Designated Operators Name: Michael Holkko Relation to the UST Facility (Check One) O Owner ElOperator 13Employee ElService Technician ■ Third -Party Business Name (if different from above): Belshire Environmental Services, Inc. Designated Operstors Phone #: (949) 450-6200 International Code Council Certification M 8025470 -UC Expiration Date: 2/2/2012 ALTERNATEI Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator 13Employee 11Service Technician ■ Third -Party Business Name (If different from above) refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: referto backup document Expiration Date: refer to backup document ALTERNATE Designated Operators Name: refer to backup document Relation to the UST Facility (Check One) O Owner 13Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to 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, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): _,.Dennis Signature of Tank Owner: Date: Owner's Phone #: (425) 427-7653 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.ce.gov/usVcontads/cupa_agys.htmi. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. ma7v72