COMPLIANCE INFO 2008-2012 - Laserfiche WebLink

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- Owner StatemenjjW Designated Underground Stor-- Tank (UST) Operator and Underst ng of and Compliance with - Aquirements Facility Name: 7-11 14117 Facility ID: 14117 Facility Address: 2725 COUNTRY CLUB BLVD Reason for Submitting this Form(Check One) STOCKTON,CA 95204 ■ Change of Designated Operator Facility Phone#: (209)463-1259 El Updated Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Jhustin Abeleda Relation to the UST Facility(Check One) Business Name(If different from above): Belshire Environmental Services, Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 1949)4605200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8036229-UC Expiration Date: 9/26/2011 ALTERNATE 1 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document ALTERNATE 2 Designated Operator's Name: refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: refer to backup document ❑ Service Technician ■ Third-Party International Code Council Certification#: refer to backup document Expiration Date: refer to backup document FRegulations, ify that, for the facility indicated at the top of this page, the individual(s) listed above will e as Designated UST Operator(s). The individual(s) will conduct and document monthly ty inspections and annual If employee training, in accordance with California Code of title 23, section 271, (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Ian Moorhead Signature of Tank Owner: Date: /2./3 Q Owner's Phone #: (916) 463-6776 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT:wawv.waterboards.ca.gov/usticontacts/cupa_agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.