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()%vller Statements of I)eSignated I Indergrotind StON"ge Tank (us,r) Operator <br /> and Understaildi"19 of and ('onipliance with I JS'F Requirements <br /> - Y <br /> RC --lacility 11)0; 813 <br /> Padficy Addiv-ss. 15.11 F:peqcadero Ave. Tracy.CA 95304 Iteason liar%ubmitting this Form <br /> Facility Phone (209) 993-7946 OChangc of Designated Operator <br /> 0 1 1pd ate Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRTMARI' <br /> Ilk-signatcd Operator's Nance:Jarrod Cooke Relation to UST Facility(Check One) <br /> Busine&,;Narne Qfdiffirenlftom ahtive): Tanknology El Owner 0 Operator 0 Employee <br /> DesignaWd Operator's Phone#: (209)371-2724 0 Service Fcchnician Third party <br /> International Code Council Certification#: 5311523-IJC Expiration Date: 7/5113 <br /> ALTERNATE I (Qpdonal) <br /> Designated Operator's Name:GEORGE SARKISS ZOIJMALAN Relation to UST Facility(Check One) <br /> Business Name Qfdj#&rentftom above):.RA4f TOX CORPORATION 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 818-429-0184 0 Sem ice Technician ®Third party <br /> International Code Council Certification#:523843941C Expiration Date: 6/21/14 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Randall Kirby Relation to UST Facility(Check One) <br /> Business Name Qf dijTerentm <br /> ft : <br /> o above): <br /> S 7-14 AJX- 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#,- 916-870-5932 Service Technician OThird-Party <br /> International Code Council Certification#: 5259566-UC Expiration Date: 04/23,2014 <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, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER/OPERATOR(Please Print): Alamo 23N38 <br /> SIGNATURE OF TANK OWNERJOPERATOR: <br /> DATE: OWNER'S PHONE q -2 <br /> NOTE: 1)suBm IT-1'H IS COM PLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> C,2RESOUR('LS UONTROI, BOARD) 11Y JANUARY 1, 2006. THE LOCAL AGENCY LIST IS AVAILABLE <br /> --AT: <br /> 2)NOTIFYTHE 14OC-AL ACJKNC,-V OF ANY CHANGFS TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Novembcr?QQ.4 <br />