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- Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:76 Facility 1D#.- <br /> Facility <br /> :Facility Address:25775 S.Patteson Pass Rd Reason for Submitting this Forth(Check One) <br /> Tracy,CA.95376 © Change of Designated Operator <br /> Facility Phone#: X Update Crrti:ficatc Expiration.Date: <br /> Designated UST Operater(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Daren R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(Ifdifferenrfrom above): ❑ Owncr ❑ Operator 11 Employee <br /> Designated Operator's Phone#:(209) 51&4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date:09/12/07 <br /> ALTERNATE 1 t'iunal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/f'dfjerent from above): ❑ Owner ❑ Operator D Employee <br /> Designated Operator's Phone#: Q Service Technician 4 Third-Party <br /> Intonational Code Council Certification#: Expiration Date- <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to U ST Facility(Check One) <br /> Business Name I di erenr rom above <br /> (,/� ff f ) ❑ Owner © Operator ❑ Employee <br /> Designated Operator's Phone#; ❑ Service Technician ❑ Third-Party <br /> International Code Councii Certification#: Expiration Date: <br /> T 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(Please Print): r—ft r <br /> SIGNATURE OF TANK OWNER: <br /> DATE:_03/27/07 OWNER'S PHONE#: ! :7_1 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY I,2045.THE LOCAL AGENCY LIST IS AVAILABLE <br /> -� AT:www.waterboards.ca,gov/i4st/,contacts/cuT)a ugys_htcril. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Z0 39dd L6ZZ56860Z TT:TT L00Z/6Z/60 <br />