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RAQUVED <br /> Owner Statements of Designated Underground Storage Tank ( <br /> 9 9 g <br /> and Understanding of and Compliance with UST Requirements FEB 0 9 2012 <br /> Facility Name: 7-11 35355 Facility ID#:35355 <br /> Facility Address: 3202 W.Hammer Lane Reason for Submitting t <br /> Stockton,CA 95209 ® Change of Designated Opera o M Vl <br /> CES <br /> Facility Phone#: 209-957-2900 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 8025470-UC Expiration Date: 1/10/2014 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (Option# <br /> Designated Operator's Name:refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document 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: <br /> DATE: 2/6/2012 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.aov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />