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10/25/2013 23:54 2094785509 PACIFIC CAR WASH PAGE 01/02 <br /> s <br /> RECEIV= <br /> 28 <br /> Owner'St'atements of Designated Underground Storage Tank(UST) PN® <br /> AL <br /> and Understanding of and Compliance with UST ReRequirements FLEA' �,,T� 6PPART� <br /> 4ENT <br /> Facility Name:Facltic Car Wash Facility ID#: <br /> Facility Address;4406 Paeific.Five Reason for Submitting this Fotarsz(Check One) <br /> Stockton,CA..95207 Chaatge of Designated Operator <br /> Facility Phone# X Updm Certificate Expiration Date <br /> pes!gnated US's Up+Mra,�tol s?.for this Faelft <br /> PRMARY <br /> Des ed operator's Naauec Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name({f drier enifr6m above).- ❑ Owner ❑ Operaw 0 Employee <br /> DesipwA operstoes Phone#:(209)5184836 o Savice Twwcim X nird-pary <br /> int octal Cade Council'Cerffication#:8032,295-M p—vuation nate:05/31/2,015 <br /> ALTERNAM,z 'aW <br /> Designated Operator's Name., Relation-to UST Faiikity(Check One) <br /> Business Name(If4(erentfrom above): 0 owner '0 .Operator Q E3�ployee <br /> Designated Opcirator"s Phone M Q Service Technician a Third-Party <br /> #International Code Council Caffication#: Expiration Dente' <br /> ALTERNATE,2 (Optiono <br /> Designated Operator's Name: Redaton to UST Facility(Cheek the) <br /> .Basiness Name(ff d(ffrsnt from above)_ Owner Q operator .© Employee <br /> Desigaetedopet�tat's.Photte#: service Tech"cian a Third-Pa ty <br /> law mationxl Code Council CeM1C4kfiQn#: Expitataon Date: <br /> 1 certify thA for the facility indicated at the top of this page,the individual(s)listed above vnll <br /> serve as Des$ ed LISTOperator(s). The individual(s)will Conduct and,document mondaly <br /> facility inspections and annual facility employee ftakiing,iu accordance with California.Code of <br /> Regulations,title 23,section 2715(c)-(f). <br /> Furthermore,T understand and am in compHance with the regal rements(statutes, <br /> regulations,and local ordinances)applicable to#underground storage.tanks. <br /> NAMEOFTANKOWNER(IPtease iP`rint): . <br /> ` <br /> SIGNATURE OF TANK OWNER: C) - <br /> DATE: 07/30/13 OWNERIS PHONE#; <br /> NOTE:1)SUSMIT CONWLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> !RESOURCES CoprfROL BOA")EX JANUARY t,2005.TRE LOCAL AGENCY LIST 19 AVAILABLE <br /> AT; M,vs.htli, <br /> 2)NOTWYAL AGENCY'OF ANY CHANGES TO 't7PDlw1 30 DAYS <br /> OF GE. <br /> Novel 2004 <br />