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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:Arco facility ID 0: <br /> Facility Address;2430 Joc PomVo Reason for Submitting this Form(Check One) <br /> Tracy,CA. 11 Change of Designated Operator <br /> Facility Phone X Update Certificate Expiration Dow <br /> Designated UST Operators)for this Facility <br /> PREM"Y <br /> Designated Operator's Name!Karen R Axnaiz Relation to CST Facility(Check One) <br /> Business Name(If abave)-, 0 (hwner , o Operator 0 Employee <br /> Designated Operator's Phone#:(209)5184836 .0 Service Tcelmician X Third-Parry <br /> Juternational Code Coancil.Certification#;'5266643-UC Expiration Date-07/16/09 <br /> ALTERNATE I L02g&ftd <br /> Designated Operator's Name- Relation to UST Focility((heck One) <br /> business Name Qf differentfrow above): C1.Owner 0 Operator 0 Employee <br /> Designated.Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification Expiration Date; <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST facility(Check One) <br /> Business Name(If d{,ftrepttfront above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#-. 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: 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, scetion 2715(c) - (f). <br /> Furthemore,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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 08/16/07 OWNER'S PHONE <br /> NOTE. 1)SURMIT THI&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.water arel s.ca.eov/ust/contact5/��e-upa aas.hLml <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Noverdber 2004 <br />