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Owner Statements of Designated. Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility CD #: <br />Facility Name: Parkwoods Valero <br />Facility Address: 1612 w, Flammcr Lune Reason for Sub,nitting this Form (Check One) <br />Stockton, CA. 95209 X Change of Designated Operator <br />® Update Certificate Expiration Date <br />Facility Phone #: (209) <br />Designated UST erator s for this Faciilr <br />PRIMARY <br />Relation to UST Facility (Check Otte) <br />Designated Operator's Namc: Ka 11 <br />Arnaiz <br />Business Name (.1f dR�`ererat from above), ❑ Owner ❑ Operator ❑ Employee <br />I?e,5ignated Operfltor's Plrone t�: {209) 57<8-836 d Service Technician X (i,ird-Party <br />international Code Council Certification #: 5266G�3-UC rxpiraticm 17atc: 07/16/09 <br />Designated Operator's Name: <br />Business Name (Ifdifferent fi-om above): <br />Designated Operator's Phone #: <br />]ntematior+al Code Council Certil~cation #: <br />ALTERNATE 2 ( 2ptfonRl) <br />Designated Operator's Name: <br />Business Name (If d;ffet nl from above): <br />Designated Operator's Phone #: <br />international Code Council Ccrt fication : <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -.Party <br />Expiration Date: <br />Relation to UST Facility (Check One) <br />❑ Owner D Operator ❑ Employee <br />❑ q,,ervica Technician ❑ Third -Party <br />Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the individua(s) listed above will <br />serve as Designated UST Operator(s).Tile individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, m accordance with (alifot-nia Code of, <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, t understand and aim in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />s 0 _ <br />SIGNATURE OF TANK OWNER: cr.- �(- ` c� p <br />®ATE: ®12/1.4/47 <br />OWNER'S PHONE #: <br />NOTE: l) SU BM11T THIS COMPLETED FORM. TO THE LOCAL AGENCY (NOT TRE, STATE WATER <br />RESOURCES CONTROL BOARD)0V JANUARY 1, 2005. LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.tivaterbos.ca.. av/ucontacwcuna—a0s,ltitmt. <br />2) NOTI1;'Y THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />