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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST requirements Facility Name: 7 ELEVEN GVR# 235090 Facility ID #: 19976 Facility Address: 1399 N MAIN Reason for Submitting this Form (Check One) MANTECA, CA 95336 ® Change of Designated Operator Facility Phone #: 209-239-3252 ❑ Update ICC # and/or Expiration Date Designated UST Operator(s) for this Facility Designated Operator's Name: Meredith Poteran Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ® Third -Party Business Name (If differentfrom above): Gilbarco Veeder-Root Designated Operator's Phone #: 916-947-5285 International Code Council Certification #: TBD Expiration Date: 3/2/2009 Al IrVDV ATV 1 /!1.6...11 Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician IM Third -Party Business Name (If different from above): Designated Operator's Phone#: International Code Council Certification P Expiration Date: AT IrVDNA'rl I !.-01...11 Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician IBI Third -Party Business .Name (If different from above): Designated Operator's Phone #: International Code Council Certification #: Expiration Date: 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 am in compli4;e�" t requirements (statutes, regulations, and local ordinances) applicabloun torage tanks. NAME OF TANK OWNER (Please Print): 7 -EI Martin SIGNATURE OF TANK OWNER: DATE: 4/9/2007 OWNER'S PHONE #: 253-796-7170 November 2004