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N1 Owner Statements of Designated Underground Storage Tank (UST) and Understanding of Compliance with UST Requirements Facility Name:COSTCO 658 Facility ID#:558 S Facility Address: 3250 W.Grantline Rd Reason for Submitting this Form(Check One) Tracy,CA 95377 M Change of Designated Operator Facility Phone#:(209)834-1247 ❑ Update Certificate Expiration Date PRIMARY Designated Operator's Name:James Wolf Relation to UST Facility(Check One) Business Name(If different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator"s Phone#:(949)460-5200 0 Service Technician ■ Third-Party International Code Council Certification#: 5296382-UC Expiration Date: 10/12/2008 ALTERNATE 1 (Optional) Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:refer is backup document ❑ Service Technician ■ Third-Party International Code Council Certification#:refer to backup document Expiration Date:refer to backup document ALTERNATE 2 (Optional) Designated Operator's Name:refer to backup document Relation to 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 Technician ■ Third-Party International Code Council Certification#:refer to backup document Expiration Date:refer to backup document Designated UST Operator(s) for this Facility 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). 'c Name of tank Owner(print): ��✓ n Signature of Tank Owner: Date: Owner's Phone# �