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of -JUN-27-2012 14 56 Service Station Systems 408 938 8888 P.02 <br />I <br />a <br />2012 <br />Owner f. of Designated Underground Storage Operator <br />c Understanding of and Compliance <br />Facility Name: Raleys Facility ID <br />Facility : 4218 IUlorada Ln, Reason for Submitting thio Porm <br />Stockton, CA 85212- 0 Change of Designated Operator <br />Facility Phone: (2(M) 956-9300 Q 'Update Certificate Eviration.Deft <br />Designated UST Opomtols) for this Facility <br />Primary <br />Designated Operators Name: Ran Casey Relation to UST Faciligoheok Otte) <br />Business Name {tidifferontftvm above): SerVire Statliah S Sorts 17 Owner 17 Operator p Employee <br />Designated Operstm'ss Phone #: 408 871-2445 IN Service Technician M Third,party <br />Int al Code Council Certification Al 8057554 -UC 5xpiration Date: 8/15/12 <br />Alternate 4 ( nal) <br />Dasoated Operatoft. Name: Maria Guarnelli Relation to. UST'Faolllb.(Chaak 0w) <br />Business Name (1f dftrent from above); Service Station Sygorris O Owner Q Operator ❑ Employee <br />Naignated Operator's Phone #; 4p8 971-2445 la SerftTechnician M Third -Party <br />international Code Council CertifrcatiorrM 8168671 Eviration Dom: 5/11/14 <br />Aftemaid 2 (Optional) <br />Dwignated Operators Name: gave Thomas Relation to. UST FacilitWCheck One) <br />Business Name (!f d0went from above): Service Station S to ma 13 Owner 0 Operator O Ernployae <br />Designated Operators Phone It 4013 971-2445 a Service Tachrilcian M Third -party <br />International Code Council Certification #: 5258666 -UC Expiration Date: 6/18114 <br />Tank Owner <br />I terljffy 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 dt.oument monthly facility Inspections and annual facility <br />employee training, in a=rdance with Galiforriia Code of Regulations, title 23, section 2716(c) - (f). <br />Furthermore, I understand and am In compliance with the requirements (statutes, regulations, and. local <br />ordinances) applicable to underground storagg tan,0. <br />Name of tank owner (Please Print): a <br />Signature of tank owners Z"f/. -° <br />Date: %&f l t owner's Phone <br />NOTE: <br />1) submit this completed form to the Local Agency (NOT the State Waster Resources Control board) <br />By January 1, 2005. The local agency list is available at: www',watorboards.ca.gov/ust/contactslcupkagys,html. <br />2) Notify the Local ncy of -any changes to this information within 30 Days of the change, <br />