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12/28/2006 16:23 2098308142 ARC082601 PAGE 01 <br /> Is & <br /> Owner Statements of Designated Underground Storage Tank(UST) Opei ator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nwne:Arco Facility ID#: <br /> Facility Address:2430 W.Grant Line Rd (Reason for Submitting this Form heck One) <br /> Tracy,CA.95376 X Change of Designated Operat <br /> Facility Phone#: ❑ Update certificate Expiration <br /> Dell ated ® tor(A Lor KacQ ty <br /> PRIMARY <br /> Drsignated OpchatorIs Name: Karen& Arnaiz Relation to UST Facility(Check C We) <br /> Business Nance(if&fferenl from above): ❑ Owner ❑ Operator 0 E mployee <br /> Designated operstoes Phone#:(209)5194836 ❑ Service Technician Y Tbi Party <br /> international Code Council Certification#:5266643-UC Expiration Date: 9/12/07 <br /> ALTERNATE I <br /> Designated Operator's Name: Relation to UST Facility(Check e) <br /> Business Name(Ifdiffer enc from above): ❑ Owner ❑ Operalor ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Tlhi -Party <br /> international Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 ( ►url) <br /> Designated Operator's Nance: Relation to UST Facility(Check ) <br /> Business Name(Ifdj ferene from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Thi -Party <br /> International Code Council Certification#: Expiration Date: <br /> 1 certify that, for the facility indicated at the top of this page,the individual(s)listed abs ve will <br /> serve as Designated UST Operator(s). The individual(s)Will Conduct and document m ��Y <br /> Facility izls�ctiolls and arcual £a�cilaty elnPloyee train ng, in accordame with CalifoxTiia Code of <br /> Regulatiolls,title 23, Section 2715(c)-(fj. <br /> Furthermore,,I understand and am in coMPOR r><ce with the"quirements(statutes, <br /> regulations,And local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Pkaw print); l l <br /> SIGNATURE OF TANK OWNER: <br /> DATE: , <br /> OWNER'S PHONE#: :PCrq-- <br /> NOTE: ')SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY I THIS LOCAL AGENCY'LIST IS AV <br /> AT:www.wa erb Srds.cay/usticontacts/cp a a LE <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO T)FIIS INFORMATION WITHIN 30 AXS <br /> OF THE CHANGE, <br /> Novemer 2004 <br />