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a <br /> 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 2705446 Facility ID#: <br /> Facility Address: 1403 Country Club Blvd. Reason for Submitting this Form(Check One) <br /> Stockton,CA 95204 X Change of Designated Operator <br /> Facility Phone#:209-943-2082 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Robert Bartel Relation to UST Facility(Check One) <br /> Business Name(If di,fferent from above): X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:530-207-9037 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5261843-UC Expiration Date:2/25/2010 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:Carmen Hildreth Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916-230-4654 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5294904-UC Expiration Date:3/22/2009 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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: JK� &.�ek <br /> DATE: 7/24/2008 OWNER'S PHONE#: 714-428-6572 <br /> San Joaquin County Dept. of Health <br /> September 2004 <br />