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owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacifityNamo: Tracy' B.P. Service Center Facility ID#: ew(o <br /> - -Z-- Reason for Submiuing this Form(Check One) <br /> Facility Address- <br /> '2375 Tracy Blvd XK change of Designated Operator <br /> Tlacy, CA- .- 0 Certificate Expiration Date Update <br /> Facility Phone#: 209-835-5356 <br /> UST_ ratirLsj_forthis FaSffi_q <br /> PRIMARY.,.. <br /> Designated Operator's Name: Bruce N. Hoagland Reh-Won to UST Fw=i1ity(Check One) <br /> o Ej OF!7 r <br /> Business Name(Ifafferentfr®mabove): Techland Testin Inc 0 Owner 0 Operator 0 Employee <br /> 0 T 0 hit <br /> Designated Operator's Phone 9: 209-724-9420 XY,Service Technician 0 Third-Party <br /> 00 <br /> E or,�D9 02 <br /> Designs <br /> XX4141013189 ExpirationDale: 11-19-2006 <br /> ALTS RNATE1 Rotation to UST Facility(Check One) <br /> Designated Operator's Name:Gary Bostrom <br /> �am a 0 <br /> Name(If&ffereniftafif 0 Owner c3 operator 0 Employee <br /> Bu ess above): Techland Testing, Inc <br /> F <br /> 420 <br /> T: <br /> —9 c <br /> Designated C9 is phom 4-. 209-724-9420 XX Smice Technician 0 TT' "P <br /> Council C <br /> _ertifi <br /> fie - 000 <br /> cation _ <br /> international Code BOK000 14 Expi 12-01-2006 <br /> rh <br /> ALTERNATE 2 (Updond) Relation to UST Facility(Check One) <br /> --tor. <br /> Designated Operator's Name: <br /> am <br /> B L E <br /> usiness Name Qf&fferenlfrom above): 0 Owner o operator 0 Employee <br /> me <br /> 7 <br /> r_s <br /> 0 SVMM-r0C&W=M 0 Thud-PaTty <br /> Designated Operator's Phow#: <br /> kInternational Code Council Certification#: Expimtion Date: <br /> NOTE.THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS, <br /> ]INFORMATION WffH]IN 30 DAYS OF THE CHANGE. <br /> I certify that,for the facility indicated at the top of this page,the individu3l(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 ter ire a (statutes, <br /> regulations,and local ordinSBces)applicable to underground storage tanks. <br /> NAME OF TANK OWNER <br /> OR OWNEWS AGENT(Please Print): V <br /> SIGNATURE OF TANK <br /> OWNER OR OWNEWS AGENT: <br /> V <br /> DATE: 14 - OWNER,'Wf�ONE <br /> T--f <br />