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5� <br /> `'JAY "1 7 2011 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator.,; <br /> and Understanding of and Compliance with UST Requirements <br /> t <br /> 7-11 14117 Facility ID#:14117 <br /> s: 2725 COUNTRY CLUB BLVD Reason for Submitting this Form(Check One) <br /> Stockton,CA 95204 ® Change of Designated Operator <br /> #: (209)463-1259 ❑ Update Certificate Expiration Dale <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operators Name: Jhustin Abeleda Relation to UST Facility(Check One) <br /> Business Name(If different from above):Be/shire Environmental Services, Inc. ❑ owner ❑ Operator ❑ Employee <br /> ❑ Service Technician N Third-Party <br /> Designated Operators Phone#: (949)460-5200 <br /> International Code Council Certification#: 8036229-UC Expiration Date: 912612011 <br /> ALTERNATE 1 O tional <br /> Designated Operators Name: refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent 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 <br /> the backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operators Name:referto 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 /> ❑ Service Technician ® Third-Party <br /> Designated Operators Phone#:refer to the backup document <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 above will serve as <br /> Designated UST Operator(s). The individua((s)will conduct and document monthly facility in <br /> and annual facility employee training, in accordance with California Code of Regulations, title 23, 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 nK. Boyd <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 5/11/2011 OWNER'S PHONE#: (714) 674-4292 <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.gov/ust/contacts/cuipa aovs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />