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C <br />San Joaquin County <br />EnvironmentalDepartmeAft <br />010 <br />3 . Weber Ave., Third Floor StocktonVk 95202 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: CA ARNG Stockton AASF <br />Facility ID #: AGTt01678 <br />Facility Address: 8010 S. Airport Way <br />Reason for Submitting this Form (Check One) <br />Stockton; CA 95206 <br />J' Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) 983-5331 or 5394 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Richard Maertz <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />K Service Technician ❑ Third -Party <br />Business Name (Ifdierent frons above): Tank Team Inc. <br />Designated Operator's Phone #: (805) 658-0067 <br />International Code Council Certification #: 524837 -UC <br />Expiration Date: 10/12/2006 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Chris Nakamura <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />)ff Service Technician ❑ Third -Party <br />Business Name (If different from above): Tank Team Inc. <br />Designated Operator's Phone #: (805) 658-0067 <br />International Code Council Certification #: "� . ( _ <br />Expiration Date: - <br />_ � is <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration 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). Theindividual(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). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME <br />SIGNA' <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/ust/contacts/eupaa ages html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />