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May, Oft 11 03:10p Reliable PetroleumA 209-845-8953 p.15 <br /> Owner St, tements of Designated Underground Storage Tank (UST) Op <br /> ator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:A-0 E GAS&FOOD Facility ID€#: <br /> Facility Address: 5 W.Grantline Road,Tracy CA 95376 Reason for Submitting this Form(Cheek 4resj' <br /> Change of Designated Operator <br /> Facility Phone#: 2 -833-3416 X Update Certificate Expiration Date <br /> Designated UST Opemtor(s) for this Facility <br /> PRIMARY <br /> Designated Operato s Name: HobertBarnhart Relation to UST Facility(Check One) <br /> Business Name{If erentftom above):Reilable Petroleum Services Inc. ❑ Owner ❑ Operator C3, Employee <br /> Designated Operator s Phone A. 209-6049336 X Service Technician ❑ Third-Party <br /> International Code C m6l Certification#: 5252540-UC Expiration Date: 12-23-2011 <br /> ALTERNATE LLO ifona! <br /> Designated Operator Name:Guadalupe Sanchez Relation to UST Facility'(Check One) <br /> Business Nance(If d erent from above):Reliable Petroleum Services Inc. p Owner ❑ Operator ❑ Employee <br /> Designated Operator s Phone#l:209-604.9363 X Service Technician ❑ Third-Party <br /> lntemational Code C iuncil Certification#: 5250451-UC Expiration Date:01-29-2013 <br /> ALTERNATE 2 (6 Wond) <br /> Designated OperatorName: Relation to UST Facility'(Check One) <br /> Business Name(Ifdr Brent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator Phone#: E3 Service Technician El Third-Party <br /> International Code C until Certification##: Exolrttion Date: <br /> 10MtifYdU1tJ0r the fMflky.indf&&ddar the top Of Ibis page,the individuals) listed above will <br /> serve as Deftpwmed UST Operator(s). The individual(s)will conduct and document xno ItWy <br /> facility inspecti and 0nUkT'fftilfty employee training, in accordance with California Code of <br /> Regulations,titic 23,section 2715(c) -(f). <br /> Furthermore,I aerstand and am in compliAnce with the requirements (statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks.. <br /> NAME OF TANK OWNER(FleassePr' }+� <br /> SIGNATURE OF I ANK OWNER: <br /> DATE; 0IJ OWNER'S PHONE#.oz d. <br /> NOTE:1)SUBhnj THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CO ROI.BOARD)BY 3ANIIARY <br /> AT:wrw. raterboar 1,200&THE LOCAL AGENCY LIST IS AVAILABLE <br /> t� s.ca ov/ustr'contactsr`Gu a ^s.html. <br /> 2)NOTIFY THE L4 OCAL AGENCY OF AN-y CHANGES TO JIM INFORMATION W1lTIfCIY 30 DAYS <br /> OF THE CHANGE <br />