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G�3CC���M�D <br /> NOV 0 1 2007 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:COSTCO#658 Facility ID#658 <br /> Facility Address: 3250 W,GRANTLINE RD. Reason for Submitting this Form(Check One) <br /> TRACY,CA 95377 ® Change of Designated Operator <br /> Facility Phone#: (209)834.1247 ElUpdate Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY _ <br /> Designated Operators Name: JAMES WOLF Relation to UST Facility(Check One) <br /> Business Name(ifalflerent from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: 949.460-6200 ❑ Service Technician ® Third-Party <br /> International Code Council Certf ication M 5296382-UC Expiration Date: 10/1212008 <br /> ALTERNATE 1 O doral <br /> Designated Operators Name: SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(H di#erenthom above) ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: ❑ service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optlonap <br /> Designated Operator s Name:SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(IfdiHerant from above). ❑ Owner ❑ operator Cl Employee <br /> Designated Operators Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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 /> Furthermor e,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 /> DEN OCCOS <br /> SIGNATURE OF TANK OWNER: <br /> DAIE: /a/ �--� j <br /> OWNER'S PHONE#: (425)427-7653 <br /> i ' <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER i <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005..THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> www.waterboards.ca.gov/ustloontacts/cupa acvs html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 3D DAYS OF THE <br /> CHANGE.. € — <br /> i <br /> I ' <br /> November 2004 <br /> I ' <br /> i <br />