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02/28/2007 19:10 2098391242 PAGE 02/02 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:VP Facility ID#: <br /> Facility Address:2375 Tracy Blvd Reason for Submitting this Form(Check One) <br /> Tracy,CA.95376 X Change of Designated Operator <br /> Facility Phone#:(209)835-5358 0 Update Certificate Expiration Date <br /> Desigflated UST OlDerator(s)for this Facility <br /> -PRIMARY <br /> Designated Operator's Name:Karen-R Arnaiz Relation to UST Facility(Check One) <br /> Business Name Qf different from above): - 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#.(209)518-4836 0 Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date:09/12/07 <br /> ALTERNATE I(Optional) - <br /> Designated Operator's Name- Relation to UST Facility(Check One) <br /> Business Name(1fdifferentfrom above).. <br /> 0 Owner El Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Idifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 11 Service Technician 0 Third-Party <br /> International Code Council Certification L 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). 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). <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(Please Print): i,6-iv-E-1N A-Al±' f- M i <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 02/28/07 OWNER'S PHONE ft: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TOT 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,%,,ov/ust/contacts/cuL)a agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />