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G° ECOVED <br /> MAR 1 0 7005 <br /> Owner Statements of Designated Underground Storage Tank (US9*0000T HEALTH <br /> and Understanding of and Compliance with UST RequiremeffigMIT/SERVICES <br /> Facility Name: Costco Wholesale Facility ID#:38 <br /> Facility Address: 1616 East Hammer Lane,Stockton,CA 95210 Reason for Submitting this Form(Check One) <br /> X Change of Designated Operator <br /> Facility Phone#: 209-475-9180 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Paula Kramer Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc. Cl Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 949-460-5200 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: See Attached Expiration Date: <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: See Attached Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Dennis Bock <br /> SIGNATURE OF TANK OWNER: Y <br /> DATE: 2/21/05 OWNER'S PHONE#: 425-427-7653 <br /> 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: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />