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Mlay•04t1 02:54p Reliable PetroleumA 845-8953 <br /> p.8 <br /> Owner S tements of Designated Underground Storage Tank (UST) Operator <br /> a Understanding Of and COmpIiance with UST Requirements <br /> Facility Namc:A H ROAD ARCO1 EAGE INVESTMENTS <br /> Facility ID#: <br /> Facility Address: 5 S.Hwy.99,Stockton CA 95212 <br /> Reason for Submitting this Form(Check One) <br /> Facility Phone#: 09 948-2438 Change of Designated Operazor <br /> X Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operat 's Nam&Roberrtart Relation to UST Facility(Check One) <br /> ierentable Petroleum Services Inc. G Owner ❑ Operator ❑ Employee <br /> 's Phon6 X Service Technician ❑ Third-Partytil52540-UC Expiration Date: 12-23-2011 <br /> ALTERNATE) bond <br /> Designated Opus 's dame:Guadalupe Sanchez Relation to UST Facility(Check One) <br /> Business Name(tfffierevftomabove):ReliablePetroleum Services inc, ❑ Owner G Operator ❑ Fmployee <br /> Designated Operal 's Phone#:209-604-9363 X Service Technician , ❑ Third-Party <br /> International Code ouncil Certification#:5250451 LTC Expiration Date: 01.29-2013 <br /> .ALTERNATE 2 ( Wlonal) <br /> Designazed Opemt 's Name: Relation to UST Facility(Check One) <br /> Business Name(I` ' erent from above): <br /> ❑ Owner ❑ Openuor ❑ Employee <br /> Designazed Opem 's Phone#: ❑ Service Technician ❑ Third-Party <br /> Intemaponal Code ouncil Certification#- Expiration Date: <br /> Fserrve <br /> fy that, r the facility indicated at the top of this page,the individual(s) listed above will <br /> s Desied UST Operator(s)- The individual(s) will conduct and document monthly <br /> facility inspec ons and annual facility employee training,in accordance with California Code of <br /> Regulations,ti le 23, section 2715(c) -(f)- <br /> Furthermore, I understand and am in compliance with the requirements(statutes, <br /> regulations, a d local ordinances).applicabllee to underground storage tasks, /! G <br /> NAME OF TAN OWNER(Please Print): � �/� U 7� �/S LG[' C do <br /> I <br /> SIGNATURE O TANK OWNER: <br /> DATE: O cJ I f NER'S PHONE#: yS <br /> NOTE: I)SUBM T THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES C( NTROL BOARD) BY JANUARY I,2005. THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:Lin�.%aterb rds.ca.-oe;-ustcontacts:crpa a�_s.hinil. <br /> 2)NOTIFY THE )CAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHAN <br />