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Dec 31 04 08: 05p Dean Sandquist 4154U55463 p. 1 <br /> From Quest GSM VAMEN.154855463 at 12/31 4:56 PM 7`t9 <br /> Owner Statements of Designated Underground Storage Tank (UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Hammer Mini Mart Facility ID#: <br /> Facility Addres.e: 3304 W Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton CA 95219-4593 ■ Change of Designated Operator <br /> Facility Phone#: L2091951-8960 O Update Certificate Expiration Date <br /> ^ ' <br /> e `� Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Erie Wayne Garcia Relation to UST Facility(Check One) <br /> Business Name(ff different from above): quest GSM n Owner n Opentor p Employee <br /> Designated Operator's Phone#: (925}756-1210 O Service Technician a Third-Party <br /> International Code Council Certification#:5094004-UC Expiration Date: 11/24/2006 <br /> ALTERNATE I COpgonap <br /> Designated Operator's Name: Relation to UST Facility(Check Ohre) <br /> Business Name(If different from above): O Owner O Operator O Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opptionap <br /> Designated Operator's Name: Relation to UST Facility(Check Ohre) <br /> Business Name(If different from above): O Owner O Operator 0 Employee <br /> Designated Operator's Phone#: ❑ Service Technician O 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): !� S <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: OWNER'S PHONE#: 411-r- 7Z 0 • 12 /Z <br /> September 2004 <br />