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Owner Statlemerlobf Designated Underground StorajIlTank (USS) Operator and Understanding of and Compliance with UST Requirements I Facility Name: COSTCO 1031 Facility Ip: 1031 Facility Address: 2440 DANIELS ST. Reason for Submitting this Form(Check One) MANTECA,CA 93336 # ❑ Change of Designated operator Facility Phone#: 2098256200 j ■ Updated Certificate Expiration Date i Designated UST Operator(s) for this Facility 4 PRIMARY Designated Operator's Name: Brian Hemandez ( Relation to the UST Facility(Check One) a F � P Business flame(If different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee 6 Designated Operator's Phone#: (949)460.5200 © Service Technician f Third Party International Code Council Certification M 53086364JC Expiration Date: 3r712011 - AI_TERNATE 1 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document t ❑ Owner ❑ Operator 11 Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document ALTERNATE 2 _ Designated Operator's 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 Operator's Phone#: refer,to backup document ❑ Service TechnicianR _ ■ Third-Party ! International Code Council Certification#: refer to backup document Expiration Date. refer to backup p document i 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 monthly7 l facility inspections and annual facility employee training, in accordance with California Code of I Regulations, title 23, section 2715(c) - (f). ' Furthermore, I understand and am in compliance with the requirements (statutes, regulations, I and local ordinances) applicable to underground storage tanks, Name of Tank Owner (print): i - J Signature of Tank Owner_ Date: � v Owner's Phonez _-_- 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,aa gav/ust/Contactslcupa agys htMI 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 3o DAYS OF THE CHANGE