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From: 949 460 52' To: 12094662201 Page: 213 Date: 3' -109 2:� (r "AR n Owner Statements of Designated Underground Storage Tan kitkJST);Pperator' and Understanding of and Compliance with UST Require , I : 1'��v i ;'i'F,1Lr_ Facility Name: MISC 930SWIL.S _ Facility 1D: 130SWILS Facility Address: 130 S. WILSON Reason for Submitting this Form (Check One) STOCKTON, CA 9520$ a Change of Designated Operator ❑ Updated Certificate Expiration Date 4 _ Facility Phone* 2094666633 Desinnated UST Operators} for this Facility PRIMARY Designated Operator's Name: Brian Hernandez Relation to the UST Facility (Check One) Business Name (If different from above): Belshire Environmental Services, Inc. ❑ Owner 0 Operator o Employee Designated Operator's Phone #: (949) 460-5200 ❑ Service Technician ■ Third -Party Intemational Code Council Certification #: 5308636 -UC Expiration Date: 416/2009 ALTERNATE 1 Designated Operator's Name: refer to backup document Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International, Code Council Certification #: refer to backup document ALTERNATE 2 Relation to the UST Facility (Check One) ❑ Owner 13 Operator ❑ Employee i ❑ Service Technician ■ Third -Party Expiration Date: refer to backup document Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) Business Name (If different from above): refer to backup document D Owner 0 Operator ❑ Employee Designated Operator's Phone #. refer to backup document o Service Technician ■ Third -Party International Code Council Certification* refer to backup documcnt Expiration Date: refer to backup document 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(c) - (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): /-/l jet ( Signature of Tank Owner -,%-- Date: II Z%� Owner's Phone #:SL NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY{NOT THE STATE WATER RESOURCES CONTROL BOAR[)) BY JANUARY f, 2005 THE LOCAL AGENCY LIST IS AVAILABLE AT: www watertwards ca 90vA1SUcontacWcupa_agys htmi 2) NOTIFY THE LOCAL AGENCY OF AN- CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE q&3g7� Nd ZLZVZ 60022/£ :91ea L/L :96ed 1,07 9917602 :orad --,� �k)