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04!29!2013 11:01AM 2098238802 QUICK AND EASY MART PAGE 01 A <br /> DECEIVE <br /> APR 26 2013 �uV <br /> Owner Statements of Designated Underground Storage Tank(UST) TOMMNMENTAL <br /> and Understanding of and Compliance with UST Requirements HEATH DEPARTMENT <br /> I <br /> !ViL <br /> Ave Reason for Submitting this Form(Cheek One) <br /> 336 X Change of Designated Operator <br /> t7 Update Certific stt Expiration Aare <br /> Desltmated UST Operator(3) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnalz Relation to UST Facility(Check One) <br /> Business Name(gdrerem from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209 518-4836 ❑ Service Technician X Third-Patty <br /> International Code Council certification#:8032295-UC Expiration Date:06/11/2013 <br /> ALTERNATEr <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdiffarenrfrorn above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:. ❑ Service Techn(cisRt t3 Third-Pam <br /> #Intematirmal Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: _,. _ Relation to UST Facility(Check One) <br /> Business Name Q(di1 eruufromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> tnranational Code Council Certification#: Expiration Date: -- <br /> I certify that,for the facility indicated at the top Of(his page,the individual(s)listed above will <br /> serve as Designated UST Operator(s). The individual(s)Will conduct and document monthly <br /> fwrhty inspections Md.arraua}faeititp'employee hwnmg, in accordance—with Cafiform&Coderof <br /> Regulations,title 23,section 2715(c)-M. <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): >' <br /> OLD <br /> SIGNATURE OFTANKOI'`ER- <br /> \\\ DATE: 04/29/13 OWNER'S PHONE N: , / S?_ l <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY t,2003•THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: wnvw waterboards ca anv/ust/coniach/cuoa ag s� himl- <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />