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San Joaquin County, <br /> Environmental Health MAY 11 2009 <br /> 600 East Weber <br /> Stockton, CA 95202 ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> And Understanding of and Compliance with UST Requirements <br /> Facility Name: Circle K Store#2701205 Facility ID#: <br /> Facility Address 16470 CAMBRIDGE Reason for Submitting this Form(Check One) <br /> LATHROP,CA 95330 0 Change of Designated Operator <br /> Facility Phone#:209-8584116 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name Rodolfo Tovar Relation to UST Facility(Check One) <br /> Business Name(1jdierent from above):Same as Above ❑ Owner ❑ Operator IZ Employee <br /> Designated Operator's Phone#: 530-681-0009 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: TOK01356 02/18/2010 <br /> ALTERNATE 1 O ' nal <br /> Designated Operator's Name: See Attached List Relation to UST Facility(Check One) <br /> Business Name(1f different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1jdiJjereni jmm above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I ceuifythatr for the-facility-indicatedat the top of this page,the individual(s) listed-above-wiij - - <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) - (t). <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 <br /> OR OWNER'S AGENT(Please Print): Heather Shields Environmental Compliance Coordinator. <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 05/0709 OWNER'S PHONE#: 951-270-5193 <br /> September 2004 <br />