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RECERIEV <br /> cFp20711 <br /> Owner Statements of Designated Underground Storageffaqk)WST) r 0 for <br /> TH <br /> and Understanding of and Compliance with UST RequMlitlentagVICES <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 Operator(s) 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 /> Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 8025470-UC Expiration Date: 21212012 <br /> ALTERNATE 1 O tional <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 ❑ Service Technician ® Third-Party <br /> International Code Council Certification*referto the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (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 ❑ Service Technician ® Third-Party <br /> International Code Council Certification*refer to the backup document Expiration Date:refer to the backup document <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed abovTwill erve as <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facipections <br /> and annual facility employee training, in accordance with California Code of Regulation23, section <br /> 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): Stephen K. Boyd <br /> SIGNATURE OF TANK OWNER: jJ4041" <br /> DATE: 9/13/2011 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.goylusticontacts/cuoa agvs.htm1. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> Wn1`) November 2004 <br />