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06/02/2008 23:33 2094785509 PACIFIC CAR WASH PAGE 01/02 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements. <br />X <br />Facility Name: Pacific Cat Wash: <br />Facility M #: <br />Facility Address; 4415 Pacific Ave . <br />Stockton. CA. 95207 <br />Reason for Submitting this Forte (Check Orse) <br />X Change of Designated Operawr <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />Designated Operator's Name: Karen. ]R Arnalz <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ operator 0 Employee <br />❑ • Service Technician X Third -Party <br />Business Name (If dtftrera from above): <br />Designated C7 mstDes Phonc #: (209) 518-M6 <br />International Code council Certification #: 5266643 -UC <br />Expiration Date: 07/16/09 <br />ALTERNATE i <br />.Designated Operators Name: <br />IicMon to LIST Facility (Check One) <br />❑ Owner, E5 Operwr p Employee <br />0 Service Ti eclmician Q 'Third -Party <br />Business Name (Ifdiferent from above): <br />Designated Operator's Phone #: <br />hmmational Code Council Certification #: <br />Expiration Datc: <br />A.X.'ll ZANA,TE 2 (4pOonat) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ .Owner 0 Operator ❑ Employee <br />0 Service Technician ❑ Third -Party <br />Business Name (If differentftom above)_ <br />Designated Operator's Phone #: <br />h4ernational Code Council Certification #: <br />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, section 2715(c) (f). <br />Furthermore, I understand and aria in compliance with the requirements (statutes, <br />regtilations, and local ordinances) applicable to underground storage tanner <br />r <br />DATE! 05/19/08 <br />i •� :! •� :r 1 i , <br />a i s1 i i '1 If 1 t i11' I p, ti <br />OF 1 <br />November 2004 <br />