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San Joaquin County 'hECEIVED <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 MAY 19 2014 <br />Owner Statements of Designated Underground Storage Hl idR NT0dr*tE ALTk <br />and Understanding of and Compliance with UST ReqdNHARTMENT <br />Facility Name: Valley Pacific Petroleum Fresno Ave Cardlock <br />Facility ID #: <br />Facility Address: 1524 Fresno Ave <br />Stockton, CA 95206 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />® Update Certificate Expiration Date <br />Facility Phone #: 209-948-9412 <br />DesiLynated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: G. Michael Eliason <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator IS Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 559 732-8381 <br />International Code Council Certification #: 5250416 -UC <br />Expiration Date:4/1/2015 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: James Abbott <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator IB Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 209 601-4641 <br />International Code Council Certification #: 8006067 -UC <br />Expiration Date: 5/15/2016 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 MI LAN K U W INEK (Please <br />SIGNATURE OF TANK OWNER: <br />DATE: 5/15/2014 <br />OWNER'S PHONE #: 209-993-8793 <br />rr,..,o...ti„, Inns <br />