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Jan,19, 2007 2:28PM West Star Environmental, Inc. No.4361 P. 2/3 <br />0% 0 16 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name- Stockton Area Office _ Facility ID # <br />Facility Address: 3330 N. Ad Art Rotel —� Reason for Submitting this Form (Check One) <br />Stockton, CA 95215 � <br />Facil' Phone #: 209-943-8666 � Change of Designated Operator <br />ata ! e Certificatc.22miration Date <br />Desimated UST Q crator s for this Facili <br />Dmignated Operator's Name: WEST STAR ENVIRONMENTAL, INC Relation to I1ST Facility (Check One) <br />13usinesc Namc (If different from above); West .Sear Environmental. INC <br />Lksiguated Operator s Phone #: 559-277-9378 <br />I International Codc Council Certification #: <br />Designated Operator's Name: <br />Business Namc (If diffe ren tfrom ahrive) ' <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: _ <br />Business Nairne (f Qjkren1 from above): <br />Desalinated Operator's Phone #: <br />international Code Council Certification #: <br />❑ Owncr l✓ Operutor u Employee <br />❑ Scrvicu Tcchnician ❑ 'Mird-Party <br />Expiration Datc: <br />Relation to UST Facility (Cheek One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third Party <br />Expiration Dots: <br />Rclation to UST Facility (Check One) <br />* Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date: <br />T certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(%). 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) - (D. <br />Furthermore, l 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): _ �v� cr,.ic� , _ fL V)NA, +C..._ <br />SIGNATURE OF TANK OWNER: - <br />DATE: OWNER'S PHONE #: (f <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT 1'HE STATE WATER <br />RESOURCES CONTROL BOARD) BY' JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.cov/usticoplEt.% tiphmll. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO TIUS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />