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Owner Statemer, _of Designated Underground Stor ,rank (UST) Operator f and Understanding of and Compliance with UST Requirements Facifityl�ame: COSTCCI0658 '^' � Facility ID: 0658 Facility Address: 3250 W. GRAINTLINE RD Reason for Submitting this Form(Check One) l TRACY,CA 95377 ❑ Change of Designated Operator i Facility Phone#: (209)830-5343 a Updated Certificate Expiration Date Desic inated UST © erator s for this Facility PRIMARY Designated Operator's i Name: Bran Hernandez - ' ., - Relation to the UST Facility(Check One) l Business Name(If different from above): Belshlre Environmental Services,Inc, ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (9499)460-5200 ❑ Service Technician a Third-Party f International Code Council Certification#: 5308636-UG Expiration Date: 3/7/2011 1 ALTERNATE 1 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check tine) l Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator`s Phone#:_ refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#; referto backup document �Expiration Date: refer to backup document • ALTERNATE 2 EDes:i�gn�atOperator's Name: refer to backup document Relation to the UST Facility(Check One) f Business Name(If different from above): refer to backup document I ❑ Owner r-i Operator ❑ Employee Designated Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Party I International Code Council Certification#: refer to backup document Expiration Date: refer to backup document 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, i and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Signature of Tank Owner: I Date; ( li' Owner's Phone NO"T"E: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 gav/ust/ContaCW[;upa_agy9 html 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE