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Owner Statements of Designated Underground Storage Tank (US�)[DO$ r�'t�r and Understanding of and Compliance with UST Requirements 76 Facility Name: BP 02076 Facility ID: 020 Facility Address: 800 E KETTLEMAN LANE Reason for Submitting this Form (Check One) LODI , CA 95240 ■ Change of Designated Operator Facility Phone#: 2093343678 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Michael Holkko 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 ■ Third-Party International Code Council Certification#: 8025470-UC Expiration Date: 1/10/2014 ALTERNATE 1 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 ❑ 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 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 ❑ Owner ElOperator ElEmployee 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 certify that, for the facility indicated at the top of this page, the individuals) listed above w7of serve as Designated UST Operator(s). The individual(s) will conduct and document month facility inspections and annual facility employee training, in accordance with California Cod 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): Rich Gossett - - - - Signature of Tank Owner: - - - - --LDate: 2/2/2012 Owner's Phone #: 714 670-3958 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/ust/contacts/cupa_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.