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0 <br />Owner Statements of Designated Underground Storage Tank (UST) <br />Operator and Understanding of and Compliance with UST requirements <br />7 <br />STOCKTON, CA 95215 <br />Phone# 209.939-0679 <br />Facility ID #: 32190 <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update ICC # and/or Expiration Date <br />Desienated UST Operator(s)for this Facili <br />Prima (Optional) <br />Designated Operator's Name: Meredith Poteran <br />Relation to UST Facility (Check One) <br />Business Name (If different from above): Gilbarco Veeder-ROOI ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: 916-947-5285 <br />❑ Service Technician ® Third -Party <br />International Code Council Certification #: TBD <br />Expiration Date: 3012009 <br />ALTERNATE I (Optional) <br />Designated Operator's Name: SEE ATTACHED LIST <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />ALTERNATE 2 (Optional) <br />Operator's Name: SEE ATTACHED LIST <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Expiration Date: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed <br />above will serve as Designated UST Operator(s). The individual(s) will conduct and <br />document monthly facility inspections and annual facility employee training <br />accordance with California Code of Regulations, title 23, section 2715(c) - ( <br />Furthermore, I understand and am in compli <br />regulations, and local ordinances) applica e t n <br />NAME OF TANK OWNER (Please Print): 7 en — R <br />SIGNATURE OF TANK OWNER: <br />DATE: 4/9/2007 OWNER'S PHONE #: 253-796-7170 <br />luirements (statutes, <br />storage tanks. <br />November 2004 <br />