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Owner Statemen A Designated Underground Stor a Tank (UST) Operator and Understanding of and Compliance with US, .tequirements Facility Name: BP 02186 Facility Address: 3212 N CALIFORNIA STOCKTON, CA 95204 Facility Phone #: 2099412694 PRIMARY Facility ID: 02186 Reason for Submitting this Form (Check One) ■ Change of Designated Operator ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facility Designated Operator's Name: Brian Hemandez Business Name (If different from above): Belshire Environmental Serives, Inc. Designated Operator's Phone #: (949) 460-5200 International Code Council Certification #: 5308636 -UC ALTERNATE1 Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Expiration Date: 4/6/2009 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 ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone #: refer to backup document ❑ Service Technician ■ Third -Party International Code Council Certification* refer to backup document Expiration Date: refer to backup document ALTERNATE 2 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 Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party 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): Chris Moul Signature of Tank Owner: Z; Date: 9/26/2008 Owner's Phone #: (714) 690-2349 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa_agys.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.