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JUL-03-2012 13:33 Service Station Systems 4q$ 938 8888 P.02 <br /> JUL 03 2012 <br /> Owner Statements of DesignatedUnderground Storage Tank .,,� <br /> and Understanding of and Compliance-with UST Require <br /> Facility Name: TM Blvd Shell& Mini Mart Facility lD#: .136186 <br /> FW14 Address: 3725 N. Tracy Blvd. Reason for Submitting this Form <br /> TraFj,CA 95376 M Change or Designated operator <br /> Facility Phone: (209)835-7608 M Update Certificate Expiration Date <br /> besi nasted US Operator(s)for this Facility <br /> Primary <br /> Designated Operator's Nance: Ran Cas Relation to GST FacilijCheO One) <br /> Business Name Of dMonant from above);' Service Station st8ms Q Owner Q Operator D Employee <br /> Designated operatore Phone#: 4.08 971 2445 0 Service Technician Qi Third-Party <br /> International Cade Council Certification#: 8057554.UC Expiration Date: 9/15112 <br /> Alternate i(Optional) <br /> Designated Operators Name: Maria Guarneili Relation to GST FaciffICheck One) <br /> Business Name(if different fir m above): Service Station$ stems 0 Omer 0 Operator ❑, Employee <br /> Designated Operators Phone#: (408)971-2445 M Service Technician I Third-Patty <br /> International Code CounrA Certification#: $155671 Expiration Date: 5111114 <br /> Alternate 2(Optional) <br /> Designated Operators Name: Dave Thomas' Relation to UST Facilib(Chook Ono) <br /> Business Name(Hditfwt ftvm above); Service Station$ #ems O Owner O Operator ❑ Employee <br /> Designated Operators Phone#: (408)971.2445 'M Service Technician M Third-Porky <br /> International Code Council 0ortficstion#: 5258566-UC Expiration Date: 6116114 <br /> TankOwner* <br /> I certify that, for the facility indicated at the top of this-page, the individual(s) listed above will serve as Designated <br /> UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training, in accordance with California Code-of Regulations,title 23, section 2715(c);(f). <br /> Furthermore,I understand and am in compilance,wi>h the requirements(statutes, regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> Name of tank owner(Please PriV): • <br /> Signature of tank owner: <br /> Date. _ M112 Owner's Phone#: MOO ' <br /> NOTE. <br /> 1)Submit this completed form to the Local Agency(NOT the State Water Resources Control Board) <br /> By January 1,2005.The local.agency list is available at: www.waterboards.ca.gov/usticontaats/cupa,_agys.html. <br /> 2) Notify the Local Agency.of any changes to this information.within 30 Days of the change. <br /> TOTAL P.02 <br /> r <br />