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3 JUN 15 2012 <br /> Owner Statements of Designated Underground storage` aTank (UST) Operator <br /> and Understanding of and Compliance with UST Regturements <br /> [Facility Name: BP 02093 _ Facility ID: 02093 <br /> Facility Address: 3425 TRACY BOULEVARD Reason for Submitting this Form (Check One) <br /> TRACY,CA 95376 ■ Change of Designated Operator <br /> rFacility Phone#: 209-835-1605 ❑ Updated Certificate Expiration Date — <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Fredy Barrita Y( <br /> Relation to the UST Facility Check One) <br /> Business Name(If different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: _(949_)460_-5200______ <br /> 949)460-5200 ❑ Service Technician ■ Third-Party <br /> j International Code Council Certification#: 8158278-UC Expiration Date: 5/9/2014 <br /> ALTERNATE11 <br /> Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: refer to backup document Expiration Date: refer to backup document <br /> ALTERNATE 2 <br /> jDesignated Operator's Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(if different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: refer to backup document Expiration Date: refer to backup document <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). jl <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> l Name of Tank Owner (print): Rich Gossett _ <br /> i <br /> i <br /> Signature of Tank Owner: <br /> I <br /> Date: 6/5/2012 Owner's Phone #: �71�670-3958 <br /> - - -- — <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY <br /> JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:www.waterboards.ca.gov/ust/contacts/cupa_agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> e <br />