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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 INC#35355 Facility ID#: Facility Address: 3202 W HAMMER LANE Reason for Submitting this Form STOCKTON, CA 95209 ❑ Change of Designated Operator Facility Phone#: (209)957-2900 ® Update Certificate Expiration Designated UST Operator(s)for this Facility PRIMARY Designated Operator's Name: MICHAEL HOLKKO Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ BELSHIRE ENVIRONMENTAL SERVICES, INC. Employee Designated Operator's Phone#: (949)460-5200 El Service Technician ® Third- Party International Code Council Certification#: 8025470-UC Expiration Date: 2/2/2012 ALTERNATE 1 (Optional) Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) Business Name(If different from above): refer to the backup ❑ Owner ❑ Operator ❑ document Employee ❑ Service Technician ® Third- Designated Operator's Phone#: refer to the backup document party International Code Council Certification#: refer to the backup Expiration Date: refer to the backup document document ALTERNATE 2 (Optional) Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) Business Name (If different from above):refer to the backup ❑ Owner ❑ Operator ❑ document Employee Designated Operator's Phone#: refer to the backup document ❑ Service Technician ® Third- International Code Council Certification#: refer to the backup Expiration Date: refer to the backup document document 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): STEPHEN K. BOYD SIGNATURE OF TANK OWNER: P40441 40� DATE: 11/1/2011 OWNER'S PHONE M (714) 771-5484 NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.aov/ust/contacts/cuoa aays.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.