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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7-11 19976 Facility ID #:19976 Facility Address: 1399 N. MAIN ST. Manteca, CA 95336 Reason for Submitting this Form (Check One) ® Change of Designated Operator ❑ Update Certificate Expiration Date Facility Phone #: (209) 239-3252 Designated UST Operator(s) for this Facility l irb'1J_rXA Designated Operator's Name: Justin Downs Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party Business Name (if different from above): Belshire Environmental Services, Inc. Designated Operator's Phone #: (949) 460-5200 International Code Council Certification #: 8021990 -UC Expiration Date: 12/7/2012 ALTERNATE 1 Mntrnnali Designated Operator's Name: referto the backup document Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑Service Technician ®Third Pavy Business Name (ffdifferent from above): refer to the backup document Designated Operator's Phone #: refer to the backup document International Code Council Certification #: refer to the backup document Expiration Date: refer to the backup document ALTERNATE 2 (Optlona/) Designated Operator's Name: referto the backup document Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee E] Service Technician ®Third -Party Business Name (if different from above): refer to the backup document Designated Operator's Phone #: referto the backup document International Code Council Certification #: reter to the backup document Expiration Date: refer to the backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and ant in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): Stephen K. Boyd SIGNATURE OF TANK OWNER: 1 DATE: 11/t5/2011 OWNER'S PHONE #: (714) 771-5484 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/usVeontacts/cupa agys.htmi. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004