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v <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209)468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Valley Pacific Petroleum Fresno Ave Cardlock Facility ID#: <br /> Facility Address: 1524 Fresno Ave Reason for Submitting this Form(Check One) <br /> Stockton, CA 95206 ❑ Change of Designated Operator <br /> Facility Phone#: 209-948-9412 IN Update Certificate Expiration Date <br /> Desienated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: G. Michael Eliason Relation to UST Facility(Check One) <br /> Business Name(1f different from above): ❑ Owner ❑ Operator [X Employee <br /> Designated Operator's Phone#:559 732-8381 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5250416-UC Expiration Date:2/26/2011 <br /> ALTERNATE 1 Optional) <br /> Designated Operator's Name:James Abbott Relation to UST Facility(Check One) <br /> Business Name(1f dif,jerent from above): ❑ Owner ❑ Operator M Employee <br /> Designated Operator's Phone#:209 601-4641 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8006067-UC Expiration Date: 3/15/2012 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1f different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Mike Eliason <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 3/30/2010 OWNER'S PHONE#: 209-993-8793 <br /> November 2004 <br />