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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: Auburn 7700 INC <br />Facility ID #: <br />Facility Address: 444 Mossdale Rd <br />Reason for Submitting this Form (Check One) <br />Lathrop, CA. 95330 <br />Change of Designated Operator <br />X Update Certificate Expiration Date <br />Facility Phone # <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Karen R Arnaiz <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician X Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: (209) 518-4836 <br />International Code Council Certification #: 8032295 -UC <br />Expiration Date: 05/31/2015 <br />AT TG'RNATF 7 Mpf; gh <br />Designated Operator's Name: Rakhi Chawla <br />Relation to UST Facility (Check One) <br />❑ Owner x❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 925-400-7118 <br />#International Code Council Certification #: <br />Expiration Date: <br />ALTF.RNATF, 2 (ODtional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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 (Please Print): _ <br />SIGNATURE OF TANK OWNER: <br />DATE: 10/31/13 OWNER'S PHONE #: <br />925-400-7118 <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 />AT: www.waterboards.ca.izov/ust/contacts/cLipa agvs.html. <br />November 2004 <br />