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*Xmer Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 'Valero, Miramar Enterprises <br />Facility ID #: <br />Facility Address: 1645 S El Dorado <br />Stockton, CA. 93246 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Oper=r <br />❑ Update Certificate Expiration Date <br />Facility Phone #. (249) 939-1946 <br />Desiotated UST Operator(s) far this Facifill <br />'Perm 0V <br />Designated Operator's Name: Karen R Arnusiz <br />Relation to UST Facility (Check One) <br />❑ Owner El Operator El Employee <br />❑ Service Technician X Third Party <br />]Business Name (Ifliferent from- above)_ <br />Designated Operator's Phone #. (209) 5184836 <br />International Code Council Certification #: 5266643 -UC <br />Expiration Date: 07/16/09 <br />All TVDhf A Ty`i 1 M-6AW nl► <br />Designaud Operator's Name: <br />Rotation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 17 Third -Party <br />Business Name (Ifciierent from above): <br />Designated Operator's Phone #' <br />International Code Council Certification #. <br />Expiration Date: <br />Ai.TT.RNATF 2 e0ndomd) <br />Designated Operator's N <br />Relation to UST Facility (Check One) <br />0 Owner ❑ Operator ❑ Employee <br />0 Service Technician ❑ Third -Party <br />Business Name (Ifdifferent from above): <br />Designated Operator's Picone # <br />International Code Council Certification #: <br />Expiration Date: <br />1 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 Uvining, 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) appReable to underground storage tanks. <br />�. A <br />NAME OF TANK OWNER (Please <br />DATE: 02/08/08 OWNER'S PHONE #-, <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WA'T'ER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS A'V'AILABLE <br />AT.- www,wattrbgardas.ca.,gov/dst/contacts/cuga a�vs.html. <br />NOTIFY ANY CHANGES TO THIS INFOi-14ATIOlU4.'1TWM-XD-Wn <br />OF t <br />November 2004 <br />