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- w p4w <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:7-Eleven 1& /73.3 Facility ID#: 17334(235061) <br /> Facility Address:4501 N Pershing Ave Reason for Submitting this Form(Check One) <br /> Stockton,CA 95207 ❑ Change of Designated Operator <br /> Facility Phone#:(209)951-6745 © Update ICC#and/or Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Ian Moorhead Relation to UST Facility(Check One) <br /> Business Name pfdii ferentfrom above):Gi/barco/Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(916)947-5285 ❑ Service Technician © Third-Party <br /> International Code Council Certification#:5250115-UC Expiration Date: 12/15/2006 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:Bob Clemens Relation to UST Facility(Check One) <br /> Business Name(Ifdi,))'erentfmm above):7-Eleven Inc. ❑ Owner ❑ Operator © Employee <br /> Designated Operator's Phone#:(714)674-4327 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5232613 Expiration Date:04/23/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Marla Murphy Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): 7-Eleven Inc. ❑ Owner ❑ Operator O Employee <br /> Designated Operator's Phone#:(925)737-4242 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5232617 Expiration Date: 10/01/06 <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 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): 711 inc-Shao-e'Partridize <br /> SIGNATURE OF TANK OWNER: <br /> DATE: I cl/OS OWNER'S PHONE#: 702-270-7160 <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 <br /> AT: www.waterboards.ca.Lov/ust/contacts/cul3a aays.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />