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Rt�G-22-2011 10:40 Service Station Systems 408 938 8888 P.02 <br /> 08/20/2011 09:18 20S4732&4 MARCH LANE 76 PAGE 01/01 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST equirements- <br /> Fain►carne: Unocal iq Z 266886 <br /> Fadrdye Address; 2701 March i_n. Mason for Submitting this Form <br /> Stockton,CA 95219 M Charge of DeSignatad OpwMor <br /> Facaity 209)473-7337 M Updaat Certlli llpa f plration date <br /> Designated UST.Operator(s)forthis Facility. <br /> Ptgnary <br /> Designated 0ptrtstors Name: DaveThomas Relatiesn to UST Facilit3{Check One} <br /> Business NiBme(if different from soova): Service Station S terfns ® Owner ® Operator Q Employee <br /> l Designated OpaMtoe's Phone# 408 971440 M Serves Technkian ® Thitd.party <br /> InwWdonm)Coda Council CerWicatian#; 5258566-UC Sxpiration mate: 7/2/12 <br /> AlWnaft i(Opffanel) <br /> Designated Oparateez Rome Rall CaseRelatiat to UST FaciliyChock erre) <br /> Business NweOfrltrent flarm above): &jVir a Station S starn9 11 Owner 0 Operator U Employee <br /> Designated Operatsots Phone4238 971-2'+44$ Ot aarvica Teehrtidan ig Third•Perty <br /> irrtomatlonatl Code Comod Cafficsocin#- 8057564.UC Cxptration gate: 9/16/12 <br /> Aiterrrate�(pptipnai) <br /> C"10nated Operators Name: Shaine Flores Ralation to LIST Fa.ENtVCheck Ona) <br /> Business Name W cWemnt ftm above): Service Stations slems 0 canner q Operator 0 Employee <br /> 06819119ted operators Phone#' <br /> 408 971 2445 Service Technician as ftrird•Party <br /> Irrtemaiiosrai Code Council Cerftfrratn!f 5249001-UC Expfratibn Date; 415/13 <br /> Tank—Owner <br /> I certify that, for the facility Indicated at the top of this page, the individual(s) listed above will serve as Designated <br /> UST Operator(s). The individuals)will conduct and document rnonfty facility inspections and annual facility <br /> employee training, in accordant a with CaliF rnia Made of RegulaIons, We 23, section 2715(0)-(f). <br /> Furthermore, I understand and am in compliance wPth the requirements (statutes, rngulatlons,and local <br /> ordinances)applicable to underground storage tanks. _ <br /> NaMe of tank owner(Palea 'nt), L <br /> Signaturree of tank o/wt'ter: <br /> Date: `-��r Ownees Phone fit: —-7 3 <br /> NOTE;" <br /> 1)Submit this completed fvrra to the Local Agency(NOT the State water Resources Control Board) <br /> By January 1,2006.The local agency list is aysfffable at; .waterbaards.ca.gov/usVc-ontacts/Guparagys.htrn. <br /> 2)Notify the Local Agency of any changes to this infontulton within 30 pays of the change. <br /> TOTAL P.02 <br />