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08/23/2007 12:27 2094669518 VALLV ARCO PAGE 01/02 <br />'-` <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />X <br />Facility Name: Arco <br />Facility ID #: <br />Facility Address: 16 E Harding Way <br />Stockton, CA. 95203 <br />Reason for Submitting this Form (Check One) <br />0 Change of Designated Operator <br />X Update Certificate Expiration Dtatc <br />Facility Phone #, <br />Designated UST Operator(s) for this Facility <br />FRiMARY <br />Designated Operator's Namc: Karen R A,rnaiz <br />Relation to UST facility (Check One) <br />❑ Owncr ❑ Operator O Employee <br />❑ Scrvicc Technician X Third -Parry <br />Business Name (If different from above).- <br />Designated Operator's Phone t~: (209) 518-U36 <br />International Code Council Certification #: 5266643 -UC <br />Expiration Date: 07/16/09 <br />ALTRRNATF. 1 /nnfinnntl <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator n Fmpinyee <br />D Servicc Technician ❑ Third -Party <br />Ruainece Nome (If different from above).' <br />Dcsignatcd Operator's Phone #: <br />International Code Council Certification It: <br />F.xniratinn Date: <br />ALTERNATE 2 (Optional) <br />Dcaignsatcd Clrerator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owncr ❑ Operator D Employee <br />n CP.rv; Technician n Third -Patty <br />Business Namc (If different from above): <br />Dcsignatcd Operator's Phonc #: <br />International Codc Council CertiFe9tion 4: <br />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 individuals) 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, l understand and am in <br />regulations, and local ordinances) appl <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE OF TANK OWNER: <br />ce with the requirements (statutes, <br />underground storage tanks. <br />— � ; v.s�) L <br />DATE: _08/23/07 OWNER'S PNONIE #: <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.cl.gov/tist/contacts/ctipa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANCES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />Novctnbcr 2004 <br />