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0 E <br /> woo-ij6-mmm//:d:4q :;!sin luoijewiolui ajow jo.1 *iaAjas xel j9XewXVj IjE)Ag PGA1900i <br /> f+..C; IVED <br /> se <br /> NOV 16 2012 <br /> Owner Statements of Designated Underground Storage Tank(UST) OpefiffiWOAQUIN COUNTY <br /> and Understanding of Compliance with UST Requirements EWIRONMENTAL <br /> HEALTH DEPARTMENT <br /> FWflitY Name: Arco AM PM Econo Gas Facility ID#., <br /> Facility;�$-. N�Ovicwrltd, Reason for Submit*g this Form(Cheek One) <br /> Lodi Ca 95240 0 Omse of Designated Operator <br /> I <br /> Facility Phone 209-369-0018 n Update Certi&ahnExpiration Date <br /> Designald..UST Qgeratorffl for this F&O <br /> PRDL4AY <br /> Desqpmted Operator's Nam David Martin Relation to UST Facility(Clieck am) <br /> Business Nome(Aydiffarorafrmij above):Fmazen-l-lift lm. Cl Ow= 0 Operator 0 Employee <br /> Dmigpated Operator's Phone#:L559)688-2977 X Service Technician a lord--Party <br /> llatern oral Code Council Certificatica fi:5246124-UC Expiration Date. Y41dd*4-tqZIt�-11( <br /> ALTERNATE I L0jj!Lxd <br /> Desiputed operator's Name: Exequiel(Jr,)Simco Relation to UST Facility(Check aje) <br /> Business Noma(1fdiffarmtfron,above):Fn=en-HjR J=. 0 Owner 0 Operator 0 Employee <br /> Deaignated Operator's Pinnae 4:(559)698-2977 XSCrVice Tcclmiciaa X11drd-Party <br /> 1Z1WMatiWd C0(12 Council Certification 9:SZ46152.UC Expiration Date- 11-12-12 <br /> ALTERNATE 2 (Opdond) <br /> De4maW Operator's Name:GW Rmmerfiel(I ROW=W UST Facility(Cheek One) <br /> Business Nam Wdifferentfitm above):Franz Hill I= 0 Owner 0 Operator 0 Employee <br /> Desipated Operators Phu=N:(559)688-2977 XService TwInician XTbird-Party <br /> International Code Council Corti imfioniV.'5246331-UC r Expiration Dat*'. 1-20-13 <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 requirem P"atotes, <br /> regulations,and local ordinances)applicable to�h�rground StOrltxeld ks <br /> NAME OF TANK OWNER(P*aw Print); <br /> SIGNATURE OF TANK OWNER: \/A, i <br /> 'V <br /> DATE: 0 OWNERISPHONE#.- <R1(6 <br /> NOTE:1)SURAOT THIS COMPLETED FORK To T=LOCAL AGENCY(NOT TSE STATE WATER <br /> RESOURCES CO BOARD)JAY JANUARY 1,2005,THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT, -vww wawwgrgEca.any <br /> VYd VC:9CZ Z 6OZ/6= :94e(] ZA :968d umoqun :woj=j <br />