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'REC OVED <br /> Owner Statements of Designated Underground Storage Tar "0)20Wrator <br /> and Understanding of and Compliance with UST MWW14ALTH <br /> Facility Name: Costco Wholesale Facility ID <br /> Facility Address: 3250 W. tline Rd.,Tracy,CA 95377 Reason for Submitting this Form(Check One) <br /> X Change of Designated Operator <br /> Facility Phone#: 209-834-1247 ❑ Update Certificate Expiration Date <br /> Designated UST operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Paula Kramer Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 949-460-5200 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: See Attached Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: See Attached Relation to UST Facility(Check One) <br /> Business Name(lfdiJferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Option,[) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifjerent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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) - (f). <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: Sz <br /> DATE: 2/21/05 OWNER'S PHONE#: 425-427-7653 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/cupa agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />