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08123/2007 10: 59 2098352297 PAGE 02 <br /> Owner Statements of Designated Underground. Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName:76 Facility ID ii; <br /> Facility Address:25775 Patterson Pass Rd Reason for Submitting this Form(Check One) <br /> Tracy.CA. ❑ Cbange of Designated Operator <br /> Facility Phone#: X i Tpdatc Certificate Expiration Datc <br /> Designated UST Ouerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R ArnaiZ Relation to UST Facility(Check Otte) <br /> Business Name(lf difterenr from above): ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: (209) 518-4836 ❑ Service Teebnician X Third-Party <br /> international Code Council Certification rt:5266643-UC Expiration Date:07/1.6/09 <br /> ALTERNATE I lional <br /> Designaled Operator's Namc: Relation to UST Facility(Check One) <br /> Business Name(Cf different fi-om above): ❑ Owner © Operator ❑ Employee <br /> Designated Operator's Phone 4; C-1 Service Technician ❑ Third-Party <br /> international Code Council Certification is F,xpimtion Date: <br /> ALTERNATE 2 (Optional) <br /> Designaled Operator's Namc: Relation to TJST Facility(Check One) <br /> Business Name(f different from above), ❑ Owner O Operator ❑ Employee <br /> Designated Operator's Phone# ❑ Service I echnician ❑ Third-Party <br /> International Code Council Certification f!: Expiration Dale: <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 /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, i understand and am in compliance with the requirements (statutes, <br /> regulatio>nis, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): PA�;FJ—' <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 08/22/07 OWNER'S PHONE#: 2 UJ o <br /> i <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO T114E LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST iS AVAILABLE <br /> AT: www.waterboards.ea-gpv/ust/contacts/cupagy_s-html- <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />