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► PECEIVED <br /> OCT 20 2011 <br /> ENVIRONMENTAL HEALTH <br /> Owner Statements of Designated Underground Storage 1P i l(�PY rator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7.11 32190 Facility ID#: <br /> Facility Address: 4943 S.STATE RT.99 <br /> Reason for Submitting this Form(Check One) <br /> Stockton,CA 95215 <br /> ® Change of Designated Operator <br /> Facility Phone#: (209)939-0679 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 8025470-UC Expiration Date: 21212012 <br /> ALTERNATE 1 O tonal <br /> Designated Operator's Name: referto the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):referto the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br /> 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): Stephen K. Boyd <br /> SIGNATURE OF TANK OWNER: .tet tt*Ul AIVIIQ <br /> DATE: 9/26/2011 OWNER'S PHONE#: (714) 771-5484 <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 AT: <br /> wwwwaterboards.ca.gov/ust/contacts/cupa aqVs.hLrTj1. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />