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Owner Statemen0of Designated Underground Stole Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: COSTCO 0038 Facility ID: 0038 Facility Address: 1616 EAST HAMMER LANE Reason for Submitting this Form(CheckOne) STOCKTON , CA 95210 ■ Change of Designated Operator Facility Phone#: (209)478.2040 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY __... Designated Operator's Name: Jhustin Abeleda Relation to the UST Facility(Check One) Business Name(if different from above): Belshlre Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee --- Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8036229-UC Expiration Date: 9/2612011 ALTERNATE 1 rBusiness signated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Name(if different from above): refer to backup document _ ❑ Owner ❑ Operator ❑ Employee _— ❑ Service Technician ■ Third-Party Designated Operator s Phone#: refer to backup document International Code Council Certification#: referto backup document Expiration Date: refer to backup document -- ALTERNATE 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 ❑ Employee Designated Operators Phone M refer to backup document — ❑ Service Technician ■ Third-Party International Code Council Certification M 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) - M. 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): Name of Tank Owner: Dennis Bock Owner's Phone#: (425) 427-7653 Signature;of Tank Owner:Date: — 0//` 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.gov/u$Vcontacts/cupa_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.