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fit-, <br /> $.V <br /> APR 3 0 2008 <br /> Owner Statements of Designated Underground Storage Talk (T JS"A�r � ry <br /> and Understanding of and Compliance with UST Requlrem t PARrMEN7- <br /> Facility Name:Gas-4-Less Facility ID#: <br /> Facility Address:3408 Manthey Road Reason for Submitting this Form(Check One) <br /> Stockton Calif X Change of Designated Operator <br /> Facility Phone#:(209)237-7895 O Update Certificate Lxpiration Date <br /> DesijZnated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnai2 Relation to UST Facility(Check One) <br /> Business Name(If dtiferent from above): 0 Owner O Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 518-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date: 07/16/09 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent f,-oin above)-- ❑ Owner D Operator Q Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date. <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST FaciIity(Check One) <br /> Business Name(If rlifl"er-ent from above): 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: O 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 <br /> serve as Designated BUST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and az IMI facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, X 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 Pi-int).Gilbert Silva <br /> i <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 05/01/08 OWNER'S PHONE#: (209)858-0101 EXt.319 <br /> NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.pov/llst/contacts/ctipa ae s.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFOPOIA,TJON WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> 5 USH 'd 90109S960Z I 'ON XVd SSHZ U 900H lid L0 :Z 1 9HM/800UH/EV <br />