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4 RECEIVED <br /> U 0 6 2013 <br /> Owner Statements of Designated Underground Storage TanlE"Tj)�" <br /> M;YTA L <br /> and Understanding of and Compliance with UST Requfi%fiPARTMENT <br /> Facility Name:Shop N Go Facility ID#.- <br /> Facility Address:4511 Pacific Ave Reason for Submitting this Form(Check One) <br /> Stockton,CA.95207 Change ofDosignated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Raz uaftd UST!Qpsiatafi)f9r thli Faft <br /> PRIMARY <br /> Designated Operator's Name.Karen R AI naiz Relation to UST Facility(Check One) <br /> Business Name(If&fferentfrom ahave): 0 Owner 0 Operator 0 Employee <br /> Designated operator's Phone#:(209)5184836 0 Service Technician X Third-Party <br /> International Code Council Certification#:8032295-UC Expiration Date:05/31/2015 <br /> ALT ERNAMLC0A�LMjd <br /> Designated Operator's Name: Relation to UST Facility(Check{Ing) <br /> Business Name(If dfferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#, 0 Service Technician 0 Third-Party <br /> #International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (OpIomd) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(ydt prentfrom above): 0 Owner 0 Operator [3 Employee <br /> Designated Operator's Phone# 0 Service Technician El Third-Party <br /> International Code Council Certification 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): 5 <br /> SIGNATURE OF TANK OWNER-- <br /> DATE: 07/30113 OWNER'S PHONE 000 <br /> NOTE: 1)SUBMIT TMS COMPLETED FORM TO THE 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.g!2v/ustleontacts/cupa acys.htm). <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />