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Sa,,.oaquin County Environmental He«f_.,, <br /> 600 E. Main Street <br /> Stockton, 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 Form(Check One) <br /> Lathrop,Ca 95330 21 Change of Designated Operator <br /> Facility Phone#: 209-858-4116 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Rudolfo Tovar Relation to UST Facility(Check One) <br /> Business Name(If different from above):Same as Above ❑ Owner ❑ Operator ® Employee <br /> Designated Operator's Phone#: 530-681-0009 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5249165-UC 09/22/12 <br /> ALTERNATE 1 (Option[ <br /> Designated Operator's Name: See Attached List Relation to UST Facility(Check One) <br /> Business Name(If 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(Ifdifferentfrom 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 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 <br /> OR OWNER'S AGENT(Please Print): Tri 1 a Yahner. Enviromn al Com liance Coordinator. <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 11/08/10 WNER'S PHONE#: 951-270-5193 <br /> September 2004 <br />