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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FaClllt Name: Fast&Easy Mart <br /> Facilit ID#: FA0001554 <br /> Facility Address: <br /> Reason for Submitting this Form (check one) <br /> [:1 Change of Designated Operator <br /> 244 W. Harding Way Update Certificate Expiration Date <br /> Stockton, Calif. 95204 <br /> Facilit Phone #: (209)948-8001 <br /> Designated UST Operator(s) for this Facility <br /> Prima Relation to UST Facility (check one) <br /> Designated Operator's name: Dan Mcllrath <br /> Business Name: Valle Under round TankMonitorin ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: (209)476-1805 ❑ Service Technician Third- a <br /> International Code Council Certification #:XX4141012575 Ex iration Date: 11/13/2006 <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification #: lExpiration Date: <br /> Alternate 2 <br /> Desi nated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: 10 Service Technician ❑ Third-party <br /> International Code Council Certification #: lExpiration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS 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 serve as <br /> Designatd UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> Name of Tank Owner ` <br /> or Owner's Agent(Please Print): 3 71 Sl ri <br /> Signature of Tank <br /> Owner or Owner's Agent: <br /> Date: 12/24/2004 Owner's Phone* (209) 948-8001 <br />