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641 <br /> FFR a <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: COSTCO 0038 Facility to: 0036 <br /> Facility Address: 1616 EAST HAMMER LANE Reason for Submitting this Form (Check One) <br /> STOCKTON,CA 95210 ■ Change of Designated Operator <br /> Facility Phone#: (209)478-2040 ❑ Updated Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to the UST Facility(Check One) <br /> Business Name(If different from above): Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (949)460.5200 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8025470-UC Expiration Date: 1/10/2014 <br /> ALTERNATEI <br /> Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: refer to backup document Expiration Date: refer to backup document <br /> ALTERNATE 2 <br /> Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) <br /> Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: refer to backup document ❑ Service Technician IN Third-Party <br /> International Code Council Certification#: refer to backup document 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: D 2/0 2 �Zol Z Owner's Phone #: (425) 427-7653 <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY <br /> JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:www.waterboards.ca.gov/usVcontacts/cupa_agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> *3-04 <br /> CILITY 1$ SUBJECT-T REINS ECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> Receive Title: <br /> EHRev UST SERVICE REQUEST INSPECTION REPORT <br />