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G <br />go <br />Ow . ner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Y Compliance with UST Requirements <br />Facility Name: Parkwoods "Valero <br />Facility 1D #: <br />Facility Address: 1612 w. Hammer Lane <br />Stockton, C -A. 95209 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) <br />nesignated UST Operator(s) for thxs,l+Acyity <br />s Name. Karen R Arnaiz <br />Business Name (If differ+entfrrom above); <br />Designated operator's Phone #: (2 )9) 518-4836 <br />Intcrnational Code Council Certification ##: 5266643 -UC <br />Relation to UST Facility (Check One) <br />❑ Owner a Operator ❑ Employee <br />❑ Servide Technician X Third -Fatly <br />Date: 07/16/09 <br />/'e,ta uay.etr w.avn v oc•.w.. <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />C owner ❑ Operator ❑ Employee <br />❑ Servide Technician ❑ 71iir&P9rty <br />l9usincss Name (Ifd&rent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated. Operator's Nwne: <br />Business Name (If different from abovel) : . _ <br />Designated Operator's Phone #: <br />.international Code Council Certification #: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />0 Service Technician ❑ Third -Party <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). 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) - (t}. <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 O (Please Print , j' V'! a''CC h OIL CORPOAATION <br />SIGNATURE OF TANK OWNER: <br />DATE: 12/144/07 OWNER, S PSH ONE 0: <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WAILER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY L19T IS AVAILABLE <br />AT: www.waterboards.ca;gov/ust/c_antacts/culta_agys.httnl- <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO MISINFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />