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0 <br />BCE #12919 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />FacilityName: Costco Gasoline Loc. No. (Manteca <br />FacilitylD#: <br />FacilityAddress: 2440 Daniels Street, Manteca <br />Reason for Submitting this Form (Check One) <br />ti Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Dennis Bock <br />Relation to UST Facility(Check One) <br />dOwner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name(lfdifferenifrom above): <br />Designated Operator's Phone#: (425) 427-7653 <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 1 (Ondonal) <br />Designated Operator's Name: Tim Hurlopker <br />Relation to UST Facility(Check One) <br />N(Owner ❑ Operator ❑ Employee <br />❑ service Technician ❑ Third -Party <br />Business Name(lfdiJferentfrom above): <br />Designated Operator's Phone #: (4 2 5) 313-8100 <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: K Y-&YV1e — <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ service Technician ffil"Thhird-Party <br />Business Name(Ifdifjerentfrom above): E- <br />Designated Operator's Phone #: C149 — LA (0� 5.2-00 <br />International Code Council Certification #: 5v215 Z -U <br />Expiration Date:0I I I I 10 9 <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I 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 training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (i). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): Dennis Bock <br />SIGNATURE OF TANK OWNER: 77 <br />I /NiN 7`�t� <br />DATE: gU4a6r7i(//ia OWNER'SPHONE#: (425) 427-7653 <br />November 2004 <br />