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Owner Stateme of Designated Underground Stoi Tank (UST) Operator <br /> and Understanding of and Compliance with UST-Requirements <br /> Facility Name: COSTCO 0658 Facility ID: 0658 <br /> Facility Address: 3250 W. GRANTLINE RD Reason for Submitting Ihis Form(Check One) <br /> TRACY,CA 95377 ■ Change of Designated Operator <br /> Facility Phone#: (209)830.5343 ❑ Updated Certificate Expiration Date J <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operators Name: Jhustin Abeleda Relation to the UST Facility(Check One) <br /> Business Name(If different from above): Belshire Environmental Services,Inc, ❑ Owner ❑ Operator ❑ Employee <br /> ...-. �-- --...- <br /> Designated Operator's Phone* (949)460-5200 ❑ Service Technician IN Third-Party <br /> IMemational Code Council Certification* 8038228-UC Expiration Date: _ _ 912612011 <br /> ALTERNATEI <br /> Designated Operators Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document ❑ Ownar ❑ Operator C Employee I <br /> Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: refer to backup document Expiration Date: referto backup document <br /> ALTERNATE 2 <br /> j Designated Operators Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document ❑ Owner C Operator ❑ Employee - <br /> Designated Operator's Phone#: referto backup document ❑ Service Technician ■ Third-Party <br /> .____ j <br /> Intema0onal Code Council Certification M refer to backup document Expiration Date: refer to backup document_J <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 /> I Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable toundergroundstorage tanks <br /> Name of Tank Owner(print): <br /> Signature of Tank Owner: <br /> Owner's Phone <br /> i <br /> -.._ - <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY <br /> 1ANUARY 1 2005 THE LOCAL AGENCY LIST IS AVAILABLE AT:www waterboards ca govrust1wntacts/cupa-agys hail <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE <br />