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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 Designated UST Operator(s) for this Facility — PAGE 2 ALILMNAI' Designated Operator's Name: Ian Moorehead Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third -Party Business Name (Ifdifferent from above): Gilbarco—VeederRoot Designated Operator's Phone #: 303-986-8011 International Code Council Certification #: Expiration Date: AL l EHINA 1 L V nonat Designated Operator's Name: Cindy Padden Larson Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Third -Party Business Name (If different from above): Gilbarco-Veeder Designated Operator's Phone #: 303-986-8011 Intemational Code Council Certification #: Expiration Date: Designated Operator's Name: Eric Banghart 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: HL 1 L' 1V \H 1 L' � vtr•w/•.• Designated Operator's Name: Rayna Guttman 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: HL1L'1V\H1G �vtiuvna•/ Designated Operator's Name: Blake Herness 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 the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): SIGNATURE OF T DATE: / 0_/� /� OWNER'S PHONE #, 253-796-7170