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Aug 31 07 09:54a Skymart Enterprizes 2099391755 p.2 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with U T Requirements <br /> Facility Name:Sky 10art Valero Fac City ID#: <br /> Facility.Address:713 N.El Dorado St Rea 5on for Submitting this Form(Check Once) <br /> Stockton,CA.9.5202 ❑ hange of Designated Operator <br /> Facility Phone#: X Update Certificate Expiration Date <br /> Desi nated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 518-4836 ❑ 3erviceTectinician X Third-Party <br /> International Code Council Certification#:5266643-UC Exp'ration Date:07/16/09 <br /> ALTERNATE 1 O lional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(if difi`erent from above): ❑ Dwner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 4: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Ex 'ration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ wner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Exy iration 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 con uct and document monthly <br /> facility inspections and annual facility employee training, in acco dance Aith 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 /> 1 SIGNATURE OF'TANK OWNER: <br /> DATE: _08131107 OWNER'S PHONE#: �`% 5'3�— / -7-S� <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGECY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCA AUNCY LIST IS AVAILABLE <br /> AT: )�.M,.tr_.waterbo.irds.ca,rov-ust/ccntacWcupa a s,haril. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />