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Ju1.30.2013 01:14 PM Er esGeneralStore 12099312871 PAGE. 1/ 2 <br /> = 1 � <br /> RECEIVE <br /> Owner Statements of Designated Underground Storage Tank(UST) OperatodUL 3 0 2013 <br /> and Understanding of and Compliance With UST Requirements SAN JOAQUIN COUNTY <br /> PKIWIPMIR.A. <br /> Facility Name:Emic's General Store Facility 1D#: HEALTH DEPARTMENT <br /> Facility Address; 4407 E Waterloo Rd Rcason for Submitting this Perm(Check Orae) <br /> Stockton,CA.95215 Change of DeAgnated Operator <br /> Facility Phone# X Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Daren R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(If d(/ferem from above): ❑ Owner p Operator ❑ Employee <br /> C Designated Operator's Phone#;(209) 518-4836 ❑ Scrviee Technichm X Third-Party <br /> Inicmational Godo Council Certification#:8032295-UC Expiration Date:05/31/2015 <br /> ALTERNATE 1 O donal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(if differenafirom above): p Owner ❑ Operator ❑ t:mpleyco <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Pavy <br /> #International Code C'nuneil Certification#: Expiration Date: <br /> ALTERNATE 2 (Oprinerd) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Businus Name(If d}Jferenr from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certilloation#: Expiration Date: <br /> 1 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 individeal(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 <br /> storage tanks. <br /> NAME O.FTANK OWNER(Please Print): I?6ug5 <br /> 7` r <br /> SIGNATURE OF TANK OWNER: I-- i <br /> DATE; !07/30/13 OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> ATt www.watcrbq_u'ds.crl. ovloft/mntpcts cttl??_"bysIL - <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OFTHECHANCE, <br /> November 2004 <br />