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May.02.2017 10:35 PM W terloo Liquors 20946,14114 PAGE. 5/ 6 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Waterloo Liquors Reason for Submitting this Form(Check One) <br /> 0 Change of Designated Operator <br /> Facility Phone#209,463 4114 0 Update Certificate Exp' VED <br /> Des' ted USI 0Vsr&t0rW for thn Facility MAY 0 3 2017 <br /> PRUIO[ARY <br /> F91 R FM HE&W <br /> Designated Operator's Name:Shawn Rodriguez Relation to UST Facility(dWel <br /> Business Name(If&fferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:559-688-2977 0 Service Technician 0 Third-Parry <br /> L International Code Council Certification#:8412602 Expiration Date:5/4/2018 <br /> ALTERNATE I COpdonal <br /> Designated Operator's Name:Gary Rummerfield Relation to UST Facility(Check One) <br /> Business Name(If&fferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:559-688-2977 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:40039 Expiration Datc:2/25/2017 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:David Martin Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner [I Operator 0 Employee <br /> Designated Operator's Phone#:559-688-2977 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:40050 Expiration Date:10/6/2016 <br /> ALTERNATE 3((Tp&na# <br /> Designated Operator's Name:Junior Sino Relation to UST Facility(Check One) <br /> Business Name(If differerafrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 9;559-688-2977 0 Service Technician 13 Third-Party <br /> International Code Council Certification#:40048 Expiration Date:1 1/11/2016 <br /> ALTERNATE 4(Oplionat) <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:559-688-2977 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:40043 Expiration Date:1/21/2017 <br /> ALTERNATE 4"Ronal) <br /> Designated Operator's Name:Jose Ochoa Relation to UST Facility(Check One) <br /> Business Name(If&fferenlfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:559-688-2977 0 Service Technician 0 Third-Party <br /> International Code Council Certification Expiration Date:1/17/2018 <br /> November 2004 <br />