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0 0 W'DECMVEgQ) <br />Owner Statements of Designated Underground Storage Tank (UST) Opera . 2 0 21110 <br />And Understanding of and Compliance with UST Requirement ' R0N,1pBj; HEALTH <br />RICES <br />Facility Name: Nella Oil #427 <br />Facility ID #. <br />Facility Address: <br />3300 Waterloo Road, Stockton, CA 95205 <br />Reason for Submitting this Form (Check One) <br />✓Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />Designated UST Operator(s) for this Facility <br />I&A ADV <br />L l\11Y1t\L\ 1 ' <br />Designated Operator's Name: Clent Gagnier <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ✓Third -Party <br />Business Name (If different from above): LG Environmental <br />Designated Operator's Phone #:(530) 521-6818 <br />International Code Council Certification #: 5243792 <br />Expiration Date: 10-17-2010 <br />T TUnXj A TC 1 //l..4 <br />PI L, A L` 1\1 \ L"1 1 1i a L v <br />Designated Operator's Name: Jacob Lyon <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ✓Third -Party <br />Business Name (If different from above): LG Environmental <br />Designated Operator's Phone #: 530 513-7828 <br />International Code Council Certification #: 8052304 <br />Expiration Date: 6-2-2010 <br />Ai TFRNATE 2 ID -in -111 <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): Amanda Appelt <br />SIGNATURE OF TANK OWNER: <br />DATE: �� an, Q OWNER'S PHONE #: _530 885-0401 <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.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />