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A 12t-26/2010 21:43 2094655220 ABC FOOD MART PAGE 01/02 <br /> DEC 2 7 2010 <br /> Owner Statements of Designated Underground Storage Tank (U ,� Operator <br /> GO, ,�, <br /> and Understanding of and Compliance with UST Require ents �, <br /> �tilerdr <br /> Facility Name- ABC Food Mart Facility ID#: <br /> Facility Address=713 N EI.Dorado St Reason for Submitting this Form(Check Otte) <br /> Stockton,CA.95202 Y Change of Designated Operator <br /> Facility Phone# Update Certificate Expiration Date <br /> nesipated UST Operator(S) for this Fs cqM <br /> PRIMARY <br /> Designated Operator's Name:Karen R Aruaiz Relation to UST Facility(Clack One) <br /> Business Name(If different from above); ❑ Owner Ll Operator 0 Employee <br /> Designated Operator's Phone_#.,(209)518-4836 Z-1 Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:06/20/2011 <br /> ALTERNATE 1 O tional <br /> Designated Operator's Name: fRelation to UST Facility(Check One) <br /> Business Name(If different from above)' Owner © Operator 0 Employee <br /> Designated Operator's Phone#: Service Technician ❑ Third-Parry <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to LIST Facility(Check One) <br /> Business Nantc(Ifdifferent from above): ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: t] Service'Technician 0 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 underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): - <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/27/10 OWNER'S PHONE <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 caQov/usticontacts/cuga agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />