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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Convenience Retailers LLC Site 2705448 <br />Facility ID #: <br />Facility Address: 3202 W. Hammer Lane <br />Stockton, CA 95209 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-957-2900 <br />Designated UST Operators) for this Facility <br />Designated Operator's Name: Robert Bartel <br />Relation to UST Facility (Check One) <br />X Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 530-207-9037 <br />International Code Council Certification #: 5261843 -UC <br />Expiration Date: 2/25/2010 <br />ALTERNATE t (Ontionail <br />Designated Operator's Name: Carmen Hildreth <br />Relation to UST Facility (Check One) <br />X Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If differentfrom above): <br />Designated Operator's Phone #: 916-2304654 <br />International Code Council Certification #: 5294904 -UC <br />Expiration Date: 3/22/2009 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 OF TANK OWNER <br />OR OWNER'S AGENT (Please Print): Stephen Boyd for ConocoPhillips <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />DATE: 7/24/2008 OWNER'S PHONE #: 714-428-6572 <br />San Joaquin County Dept. of Health <br />September 2004 <br />