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4 Owner Statements of Designated Underground Storage Tank(UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7-1132262 Facility ID: 32262 Facility Address: 2360 W.GRANT LINE RD. Reason for Submitting this Form(Check One) TRACY,CA 95376 - ■ Change of Designated Operator Facility Phone#: (209)830-9917 ❑ Updated Certificate Expiration Date Designated UST Operator(s)for this Facility PRIMARY Designated Operator's Name: Jhustin Abeleda Relation to the UST Facility(Check One) BusinessName(if different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone M (949)460-5200 ❑ Service Technician ■ Third-Party International Code Council Certification It 8036229-UC Expiration Date: 9/26/2011 ALTERNATEI Designated Operators Name: refer to backup document Relation to the UST Facility(Check One) Business Name(if different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operators Phone M refer to backup document ❑ Service Technician ■ Third-Party i Intemational Code Council Certification#: refer to backup document Expiration Date: referto backup documenf ALTERNATE 2 Designated Operators Name: refer to backup document 'Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification# refer to backup document j Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s)- The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c)- {f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances)applicable to underground storage tanks, Name of Tank Owner(print): Ian Moorhead Signature of Tank Owner: Date: Owner's Phone#: (916)463-6776 I NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY .JANUARY 1,2005 THE LOCAL AGENCY LIST IS AVAILABLE AT:www waterboards ca.gov/ust/contacts/cupa agys html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.