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NOV 2 2 2011 <br />OUN <br />Owner Statements of Designated Underground Storage Tank UST Q'A�_`�u�'����TAL ; <br />g g g { ) �1D�V40?Ei`VTAL <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 7-11 19976 <br />Facility ID #: 19976 <br />Facility Address: 1399 N. Main St. <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />® Update Certificate Expiration Date <br />Facility Phone #: (707) 664.8326 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Justin Downs <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (/f different from above): Belshlre Environmental Services, Inc. <br />Designated Operator's Phone #: (949) 460.5200 <br />International Code Council Certification #: 8021990 -UC <br />Expiration Dale: 121712012 <br />ALTERNATE 1 f0ut/onal) <br />Designated Operator's Name: refer to the backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different from above): refer to the backup document <br />Designated Operator's Phone #: refer to the backup document <br />International Code Council Certification #: refer to the backup document <br />Expiration Date: refer to the backup document <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: refer to the backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (lfdifferent from above): refer to the backup document <br />Designated Operator's Phone #: refer to the backup document <br />International Code Council Certification #: refer to the backup document <br />Expiration Date: refer to the backup document <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br />Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br />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 OF TANK OWNER (Please Print): Stephen K. Boyd <br />SIGNATURE OF TANK OWNER: J <br />DATE: 10/20/2011 OWNER'S PHONE #: (714) 771-5484 <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 AT: <br />www.waterboards.ca,gov/ust/contacts/cul)a agys,html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />1OQ7,5q� November 2004 <br />