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A <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 7-Eleven,Iot. /99 741 <br />Facility ID #: 19976 (235090) <br />Facility Address: 1399 N Main <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />El Update ICC # and/or Expiration Date <br />Facility Phone #: (209) 239-3252 <br />Designated UST Ouerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Ian Moorhead <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑O Third -Party <br />Business Name (Ifdierent from above): Gilbarco/Veeder-Root <br />Designated Operator's Phone #: (916) 947-5285 <br />International Code Council Certification #: 5250115 -UC <br />Expiration Date: 12/15/2006 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Bob Clemens <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator O Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdifferentfrom above): 7 -Eleven Inc. <br />Designated Operator's Phone #:(714) 674-4327 <br />International Code Council Certification #:5232613 <br />Expiration Date: 04/23/06 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Marla Murphy <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator OO Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdii ferentfrom above): 7 -Eleven Inc. <br />Designated Operator's Phone #:(925) 737-4242 <br />International Code Council Certification #:5232617 <br />Expiration Date: 10/01/06 <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 <br />SIGNA' <br />DATE: <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />