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FROM FAX NO. r. 03 2014 10:11PM P1 <br /> Mcnc:ll 11M <br /> wtv, 0 4 2014 <br /> ENVIRONMENTAL <br /> EALTH <br /> Owner Statements of Designated Underground Storage Tank(UST)(�;gltorDEPARTMENT <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name;SD Gas Facility ID#' <br /> Facility Address.,515 W.1116 Stroet Ram for Submitting this Form(Check Om) <br /> Tracy,CA.95376 x Chanp Of Daigraw Operator <br /> Facility Phone# Updme Certificate Expindon Date <br /> Des' aced 01 Qgmtkoda)for ft ELOA <br /> PRUMARY <br /> R!!Lpatcd operatoes Name.Karen R Aruaiz Relation to UST Facility(Check One) <br /> Business Name(I,f'diffeFentfrom above); 0 Owner 13 Operator 0 Employee <br /> Designated Operator's Phone#:(209)51"36 0 Service Technician X Third-Party <br /> international code comcii cAoitication#!8032295-UC Expiration Date;05/31/2015 <br /> ALTERNATE ILOptqL^jf_ <br /> Wignated Operatw'sNamc-, Relation to LIST Facility(Check One) <br /> Business Name(ifdifferentfrom above): 0 Owner 0 Operator 13 Employee <br /> Designated Operator's Phone#: 13 Service Technician 0 Third-Party <br /> Antanational Code Council Certification 0; Expiration Date, <br /> ALTMATE 2 (OpdanaQ <br /> Desipated Opmator's Nme, Relation to UST'Facility(Check One) <br /> Business Name(If differentfivw above): C3 Owner 0 Operator 0 Employee <br /> Designated Opavlxw's Phone 0 Sc rvicc Technician a Third- <br /> International Code Council Certification#; Expiration Datc: <br /> I certify that,for the facility indicated at the top of this page,the individual(s)Wed above will <br /> sme as Designated UST Operator(s). The individuals)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)-(0. <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(Plesse Print): Sa 11 scey r I!°„1 <br /> -SIGNATURE OF TANK OWNER: <br /> DATE; 02/24/14 OWNERISPRONE N: (al o) q/q-539f6 <br /> L <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,205.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:WWW.waWftgEdj,r&&gvj0t1pqnMMLcuM pgysL <br /> .bgk <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANCES TO THIS INFORMATION WITWN 30 DAYS <br /> OF THE CHANGE. <br /> Novffaber 2W <br />