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04 i <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7-11 14117 Facility ID#:14117 <br /> Facility Address: 2725 COUNTRY CLUB BLVD Reason for Submitting this Form(Check One) <br /> Stockton,CA 95204 ® Change of Designated Operator <br /> Facility Phone#: (209)463-1259 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> ❑ Service Technician ® Third-Party <br /> Designated Operator's Phone#: (949)460-5200 <br /> International Code Council Certification#: 8025470-UC Expiration Date: 111012014 <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(if different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document <br /> ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE (Optionao <br /> Designated Operators Name:refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#:refer to the backup document <br /> ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> Fannual <br /> or the facility indicated at the top of this page,the individual(s) listed above will serve as <br /> ST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> cility employee training, in accordance with CaliforniaCode of Regulations, title 23, sectione,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): Stephett K�Btoy'd <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2/6/2012 OWNER'S PHONE#: (714) 771-5484 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> www.waterboards.ca.qov/ust/contacts/cupa acvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />