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05/23/2008 10:04 <br />2099316743 <br />I4ATERL00 SHELL <br />PAGE 01 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />.Facility Name: Waterloo Shefl � <br />_ <br />Facility ID #: <br />Facility Address: 4315 E_ Waterloo Rd <br />Reason for Submitting this Form (Check One) <br />Stockton, CA. 95205 <br />X Change of Designated Operator <br />❑ Update Certiticate Expiration Date <br />Facility Phone #' <br />Desi <br />anated UST dpmtor(s) for this Fsrility <br />PRIMARY <br />Designated operator's Name: Karen R Arnaia <br />Relation to UST Facility (Check (Are) <br />0 Owner O Operator O Employee <br />❑ Service Technician X Third -Parry <br />Business Name (Ifdr,'Berent from above): <br />Designated Operator's Phone #: (209) 5184836 <br />International Code Council Certification #: 5266643 -UC <br />Expiration Date: 07/16/09 <br />ALTERNATE 1(Opdonal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner 0 Operator 0 Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If deerent from above) : <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Opdoxal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />0 Service Technician O Third -Party <br />Business Name (lf different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 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 (Pkase <br />SIGNATURE OF TANK OWNER: <br />DATE: 05/23/08 <br />OWNER'S PHONE #: <br />2-0 4� - ` 3 <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL. AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 240 LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/ust/contact5./gypa agyY_httnl. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO )►TO4;qUN 30 DAYS <br />OF THE CHANGE. <br />MAY 2 3 2008 November 2004 <br />SAN JCAQUIN COUNTY <br />ENVIRONMENTAL <br />HEAL' H DEPARTMENT <br />