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Is SEIIW-01-2011 12:43 Service Station Systems 408 938 8888 P.04 4E �,rZ, Owner Statements of Designated Underground Storage Tank (UST) up&htiar and Understanding of and Compliance with UST Require metp AQIAV GOONry C"VIFONMENTAL HEALTH co . Facility Name: �MpwwV Facility to#; 2707 Facility Address: 5425 N.IDacific Ave. Reason for Submitting this Form Stockton, CA 95207- M Change of Designated Operator Facility Phone: (209)472-8600 la Update Certificate Expiration Date Designated LIST Operator(s)for this Facility Primary Designated Operators Name: Bryan Lundien Relation to UST Facilitt(Check One) Business Name(If different from above); Service Station Systems ❑ Owner ❑ Operator ❑ Employee Designated Operators Phone#: 408 971-2445 fa Service Technician 2 Third-Party International Code Council Certification#: 8001468-UC Expiration Date: 8/16/13 Altemate 1 (Optional) Designated Operator's Name: Ran Casey Relation to UST Facilig(Check One) Business Name(I(different from above): Service Station Systems ❑ Owner ❑ Operator 0 Employee Designated Operators Phone#: (408)971-2445 ® Service Technician ® Third-Party International Code Council Certification#: 8057554-UC Expiration Date: 9/15/12 Altemate 2(Optional) Designated Operators Name: Dave Thomas Relation to UST FacilitxCheck One) Business Name(if different from above); Service Station Systems 0 Owner ❑ Operator ❑ Employee Designated Operators Phone#: 408 971-2445 [a Service Technician 19 Third-Party International Code Council Certification#: 5258566-UC Expiration Date: 712/12 Tank Owner I 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, 1 understand and am in compliance with the requirements (statutes, regulations, and local ordinances)applicable to underground storage tanks. Name of tank owner(Please Print): gs-z, Signature of tank owner: Date: A/.�/�[t Owner's Phone#: 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. TOTAL P.04