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Owner Statemen f Designated Underground Sto a Tank (UST) Operator and Unders�ing of and Compliance with USWequirements [Facility acility Name: 7-1132190 Facility ID: 32190 acility Address: 4943 S. STATE RT. 99 Reason for Submitting this Form(Check One) STOCKTON, CA 95215 ■ Change of Designated Operator Phone#: (209)939-0679 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facilitv PRIMARY p "Council e: Jhustrn Abeleda Relation to the UST Facility(Check One) from above): Belshire Environmental Services, Inc. ❑ Owner ❑ Operator ❑ Employee e M (949)4605200 ❑ Service Technician ■ Third-Party ertification#: 8036229-UC Expiration Date: 9/26/2011 ALTERNATE 1 ffDesignated ed Operator's Name: refer to backup document Relation to the UST Facility(Check One) Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party nal Code Council Certification#: referto backup document Expiration Date: refer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): referto backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator s Phone#: refer to backup document ❑ Service Technician ■ Third-Party Intemational Code Council Certification#: referto 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(x) - (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): Ian Moorhead Signature of Tank Owner: [Date: m A /0 9 Owner's Phone #: (916) 463-6776 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.ca.gov/usttcontacts/cupa_agys.htmi. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.