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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: TESORO USA 68152 Facility ID: 68152 Facility Address: 401 w KETTLEMAN LANE Reason for Submitting this Form (Check One) LODI, CA 95240 ■ Change of Designated Operator ❑ Updated Certificate Expiration Date Facility Phone #: 2093688787 Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Laura Gomez Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): Belshire Environmental Services, Inc. Designated Operator's Phone #: (949) 460-5200 International Code Council Certification #: 8344748 Expiration Date: 4/14/2017 ALTERNATE1 Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Expiration Date: refer to backup document ALTERNATE Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Burke Albelda, TESORO SIERRA PROPERTIES LLC RECEIVED Signature of Tank Owner: - MAR 0 7 2016 Date: 5/5/2015 Owner's Phone #: (310) 869-4096 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONT JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: vmw.waterboards.ca.gov/ust/contacts/cupa_agys.htmi. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.