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Lj <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: COSTCO 0038 <br />Facility ID: 0036 <br />Facility Address: 1616 EAST HAMMER LANE <br />STOCKTON , CA 95210 <br />Reason for Submitting this Form (Check One) <br />a Change of Designated Operator <br />D Updated Certificate Expiration Date <br />Facility Phone #: (209) 478.2040 <br />Designated UST Operator(s) for this Facility <br />RR!MARV <br />Designated Operator's Name: Michael Holkko <br />Relation to the UST Facility (Check One) <br />❑ Owner ❑ Operator D Employee <br />O Service Technician ■ Third -Party <br />Business Name (If different from above): Belshire Environmental services, Inc. <br />Designated Operator's Phone If: (949) 460.5200 <br />International Code Council Certification #: 8025470 -UC <br />Expiration Date: 1/1012014 <br />ALTERNATEI <br />Designated Operator's Name: refer to backup document <br />Relation to the. UST Facility (Check One) <br />D Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): refer to backup document <br />Designated Operator's Phone #: refer to backup document <br />International Code Council Certification #: refer to backup document <br />Expiration Date: refer to backup document <br />ALTERNATE2 <br />Designated Operator's Name: refer to backup document <br />Relation to the UST Facility (Check One) <br />o Owner ❑ Operator o Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (if different from above): refer to backup document <br />Designated Operator's Phone #: refer to backup document <br />International Code Council Certification #: refer to backup document <br />Expiration Date: refer to backup document <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, regulations, <br />and local ordinances) applicable to underground storage tanks. <br />Name of Tank Owner (print): Dennis Bock <br />Signature of Tank Owner: <br />Date: 0 2� Z �Zoi 2 Owner's Phone #: (425) 427-7653 <br />JANUARY 1, 2005. HSUBMITTHIS COMPLETED E OCALAGENCYL ST S AVAILABLE ATM TO THE : <br />N�waOTrToards.ca.gov str onto tsrcu6tC[diflht�ll 11 ( V <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. 111''1"A 1 <br />