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San Joaquin Co. Enviro., Health Division <br /> 304 E. Weber Ave., Third Floor <br /> Stockton, CA 95202 <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#: 3763 <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: Michelle Wilson Relation to UST Facility(Check One) <br /> Business Name(If different from above):Same as Above ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: 951-270-5193 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5234430-UC Expiration Date: 05/13/2006 <br /> ALTERNATE 1 clonal <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(Ifdif/erent from 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 /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Michelle Wilson, Environmental Compliance Mgr. <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 2/18/05 OWNER'S PHONE#: 951-270-5193 <br /> September 2004 <br />