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RECEIVED <br /> NOV 16 2012 <br /> Owner Statements of Designated Underground Storage Tank(USTPIMMaNTY <br /> and Understanding of and Compliance with UST RequiremCMVH DEPARTMENT <br /> Facility Name. 24 Hour Gas&Mat Facility ID# <br /> Facility Address: 1901 $Eldorado St Reason for Submitting this Form(Check One) <br /> Stockton,Ca.95206 X Change of Designated Operator <br /> Facility Phone# Update Certificate Expiration Date <br /> DesjUated U 0gerator(s)for tisFacility <br /> p <br /> Designated Operator's Nme;Karen R Arnaiz Relation to UST Facility(Check One) <br /> Susinm Name(11difforentfrom above): L3 Owner C3 Operator 0 Employee <br /> Designated Operator's Phone#:(209)5184836 0 Service Technician X Third-Party <br /> Int national code Council Certification#:8032295-UC -Expiration Date:06/11/2013 <br /> ALTERNATE I i(andanaf) <br /> Designated Operator's Name; Relation to UST facility(Check Ong) <br /> Businm Name(If de&r*Pafrvm above): 0 Owner 0 Operator 0 Employee <br /> —Designated Operator's Phone#: 0 Servke Technician 0 Third-Parry <br /> L#lUtemadonal Code,Council Certification#! Expiration Date: <br /> ALTERNATE 2 opdoxd) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner Q Operator 0 Employee <br /> Desi ed Operator's Phone#, 0 Service Technician 0 Third-Party <br /> International Code Council Certifwxdon#: 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)win Conduct and document monthly <br /> facility inspections and annual facility employee training,in accordance with Cali OMia 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 /> NAMEE OF TANK OWNER(Please P - I — <br /> SIGNATURE OPT 0 <br /> DATE- 11/15/12 OWNER'S PHONE#-Ae-/Cpe -7:>v 71 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES COOLBOARD)BY JANUARY 1,2005-TELE LOCAL AGENCY LIST IS AVAILABLE <br /> AT; <br /> 2)NOTWY THE LOCAL AGENCY OF ANY CHANGES To THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> ZO/TO 39Vd VI6931V 9960T9060ZT LT:ST ZTOZ/91/11 <br />