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San Joaquin County <br /> Environmental Health Department <br /> 600 East Main Street <br /> Stoddon, CA 95202-3029 <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 Foran(Check One) <br /> LATHROP,CA 95330 IBJ Change of Designated Operator <br /> Facility Phone#: (209)85&4116 ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Opaabor's Name Terrence Nutt Relation to UST Facility(Check One) <br /> Business Name(Ijd fferenrfrom above):Same as Above ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: (209)6284642 ❑ Service Technician ❑ Thud-Party <br /> International Code Council Certification#: 5305236-UC Expiration Date: 7/17/09 <br /> ALTERNATE <br /> Designated Operator's Name: See Arached Lisr Relation to UST Facility(Check One) <br /> Business Name(ydi,B"erenifrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opdonal) <br /> Designated Operator's Name: Relation to UST Facility(Check Ox) <br /> Business Name(Ifdr$erentfroev above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Thw&Party <br /> International Code Council Catification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHUK 30 DAYS OF THE CHANGE. <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 OWNEROR OWNER'S AGENT(Please Print): Rich Gossett, Env. Com. NW, <br /> SIGNATURE OF TANKOWNER OR OWNER'S AGENT: <br /> DATE: 6/06/08 OWNER'S PHONE#: 951-270-5193 <br /> Sept 2004 <br />