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L� I. II v/Lr=Lo <br /> ` <br /> SEP 1 6 2010 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Valero Comer Store#3641 Facility ID#: FA0003730 <br /> Facility Address: 1210 Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95210 ❑ Change of Designated Operator <br /> Facility Phone#:209-477-3111 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Donald W.Marcetti Relation to UST Facility(Check One) <br /> Business Name(If different from above): Valero <br /> ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 209-601-2373 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8016976 Expiration Date: 8/13/12 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above:Valero ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): Valero ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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 OWNERS AGENT (Please Print): Sandy Huff <br /> SIGNATURE OF TANK OWNER <br /> OR OWNERS AGENT: <br /> DATE: 4 , / OWNER'S PHONE#: 559-583-3298 <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 <br /> AT: www.waterboards.cagov/ust/contacts/cupa_agys.html. <br /> November 2004 <br />