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RECEIVED FAXED <br /> __II � 3 <br /> (3v r'ne r Ua't'e'ments of Designated Underground Storage Tank (UST) Operator <br /> SAN JOAQI 0 erstanding of and Compliance with UST Requirements <br /> ENVIRONMENT <br /> Face e: AeM Facility ID#: <br /> Facility Address: 7700.Moreland Ct Reason for Submitting this Foran(Check One) <br /> Stockton,CA,95212 Change of Designated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz � Relation to UST Facility(Cheek One) <br /> Business Namc(If dt, rent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)518-4836 - ❑ Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:05/31/2015 <br /> ALTERNATE 1. O Uonai <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(!f d Brent from above?' p O'wrier ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service'rechnician ❑ Third-Darty <br /> #Intemationai Code Council Certification#- Expiration bate <br /> ALTERNATE 2 (Optional} <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from boll)! ❑ Owner ❑ Operator ❑ Employee <br /> Designated operator's Phone#: ❑ 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 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 /> regulations,and local ordinances) applicable to undergoround storage tanks. <br /> NAME OF TANX OWNER(Please Print <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 07/26/13 OWNER'S PHONE#: '�- s'' ct -7 S^ _5 I ~~ <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 AVAJLABL)E <br /> AT:www.vy r g ( ca, 4viustl ntacts/cepa ays-htrnl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />