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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: Waterloo Liquors <br />Facili!y ID#: FA0004064 <br />Facility Address: <br />Reason for Submitting this Form (check one) <br />2512 E. Waterloo Rd. <br />1771 Change of Designated Operator <br />Stockton, Calif. 95205 <br />Update Certificate Expiration Date <br />I <br />Facili�L Phone #: (202) 463-4114 -f <br />Designated 0 <br />Relation to UST Facility (check one) <br />Business Name: <br />Designated Operators Phone #: <br />International Code Council Certification #:XX4141012575 <br />Designated Operator's name: <br />Relation to UST Facility (check one) <br />Owner ElOperator DEmployee <br />El Service Technician El Third-pady <br />Business Name: <br />Designated Operators Phone #: <br />'International Code Council Certification #: �Expiration Date: <br />Designated Operators name: <br />',Relation to UST Facility (check one) <br />0 Service Technician 11 Third-Rarty <br />Designated Operators Phone #: <br />IlInternational Code Council Certification #: Expiration Date: <br />Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br />THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />e Mp oY Yrils page, Me Inaffl-105f Msffsfe-d 56600 will serve as <br />Designatd UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, <br />ilame of Tank Owner <br />WWII - <br />Signature of Tank <br />|Daba 12/18/2004 <br />