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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: COSTCO 1091 Facility ID: 1091 Facility Address: 2680 REYNOLDS RANCH PKWY Reason for Submitting this Form (Check One) LODI,CA 95240 m Change of Designated Operator Facility Phone#: 2093667332 1 0 Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Thomas Cervantes Relation to the UST Facility(Check One) Business Name(If different from above): Beishire Environmental Services,Inc. 0 Owner 0 Operator El Employee �-D--es-ig-n--a-t-e-d--O--pe-r-a-t-o--r'-s---P-h--o---n-e-#:- --(9-49--)46-0--5-2-0-0- 11 Service Technician ■0 Third-Party I ------- —, � -- --- -- ----------- ------------------- i International Code Council Certification#: $222755 Expiration Date: 10/4/2015 ALTERNATE Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document 11 Owner 11 Operator 11 Employee Designated Operator's Phone#: refer to backup document Ei Service Technician N Third-Party : International Code Council Certification#: refer to backup document Expiration Daterefer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup document -i Relation to the UST Facility(Check One) ------- - --- - --. " ,, -, -- - --- -- 1 Business Name (if different from above): refer to backup document 0 Owner 13 Operator 13 Employee Designated Operator's Phone* refer to backup document El Service Technician 0 Third-Party i International Code Council Certification#: refer to backup document 1 Expiration Date: refer to backup document 1 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): Dennis Bock Signature of Tank Owner: Date: 12/4/2013 Owner's Phone #: (425) 427-7653, NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:www.waterboards.ca.gov/ust/contacts/cup4_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITKIN 30 DAYS OF THE CHANGE.