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Owner Statemer f Designated Underground Sto&e Tank (UST) Operator and Understdnding of and Compliance with U Zequirements [Facility cility Name: BP 09600 Facility ID: 09600 cility Address: 1250 N WILSON WAY Reason for Submitting this Form (Check One) STOCKTON,CA 95205 ■ Change of Designated Operator Phone#: 2094655359 ❑ Updated Certificate Expiration Date Designated UST Operator(s) for this Facilitv PRIMARY Designated Operators Name: Brian Hernandez Relation to the UST Facility(Check One) Business Name(If different from above): Belshire Environmental Senves, Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operators Phone M (949)460-5200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 5308636-UC Expiration Date: 4/6/2009 ALTERNATEI E ed Operator's Name: refer to backup document Relation to the UST Facility(Check One) Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee ed Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Party nal Code Council Certification* refer to backup document Expiration Date: refer to backup document ALTERNATE2 Designated Operators 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 Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document FFurt1rhermore, eify that, for the facility indicated at the top of this page, the individual(s) listed above will rve as Designated UST Operator(s). The individual(s) will conduct and document monthly iity inspections and annual facility employee training, in accordance with California Code of gulations, title 23, section 2715(c) - (f). I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Chris Moul �/ �� Signature of Tank Owner: L— � Date: 9/26/2008 Owner's Phone #: (714) 690-2349 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.