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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 #19976 Facility ID #: Facility Address: 1399 N. Main, Manteca Reason for Submitting this Form (Check One) ❑ Change of Designated Operator ❑ Update Certificate Expiration Date Facility Phone #: 209-239-3252 Desil4nated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Daniel Perez Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third -Party Business Name (If dlerent from above): Gilbarco-VeederRoot Designated Operator's Phone #: 303-986-8011 International Code Council Certification #: Expiration Date: ALTERNATE (Optional Designated Operator's Name: Marla Murphy Relation to UST Facility (Check One) ❑ Owner ❑ Operator Employee ❑ Service Technician ❑ Third -Party Business Name (If di, fJerent from above): 7 -Eleven, Inc. Designated Operator's Phone #: 925-699-9795 International Code Council Certification #: Expiration Date: ALTERNATE (Optional) Designated Operator's Name: Robert Clemens Relation to UST Facility (Check One) ❑ Owner ❑ Operator � Employee ❑ Service Technician ❑ Third -Party Business Name (If dierent from above): 7 -Eleven, Inc. Designated Operator's Phone #: 714-394-6005 International Code Council Certification #: 5232613-uc Expiration Date: 4/23/2006 ALTERNATE (Optional) Designated Operator's Name: Darren Austin Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third -Party Business Name (If different from above): Gilbarco-VeederRoot Designated Operator's Phone #: 303-986-8011 International Code Council Certification #: Expiration Date: ALTERNATE (Optional) Designated Operator's Name: Darryll Riley Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third -Party Business Name (If different from above): Gilbarco-VeederRoot Designated Operator's Phone #: 303-986-8011 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 compliance with th�requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks.,X` NAME OF TANK OWNER (Please Print): SIGNATURE OF T. DATE: /-? /��/C) V OWNER'S PHONE #: 253-796-7170