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0.4'N 12 2009 Owner Statements of Designated Underground Storage Tank.,(U6T4A""l6V. .i and Understanding of and Compliance with UST Requirement• ,,/, E VIES Facility Name: COSTCO 0658 Facility ID: 0658 Facility Address: 3250 W. GRANTLINE RD Reason for Submitting this Form (Check One) TRACY,CA 95377 ■ Change of Designated Operator Facility Phone#: (209)830-5343 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Brian Hernandez Relation to the UST Facility(Check One) Business Name(If different from above): Belshire Environmental Services, Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (949)460-5200 ❑ Service Technician N Third-Party International Code Council Certification#: 5308636-UC Expiration Date: 41612009 ALTERNATE 1 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 L Employee Designated Operator's Phone#: referto backup document ❑ Service Technician 0 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 Ll Owner ❑ Operator ❑ 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 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): Signature of Tank Owner: Date: Zllqlc 9___ Owner's Phone #': 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.govlust/contacts/cupA_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.