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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 /> Facil iffy tame:7-ELEVEN#32262 Facility ID#: 235423 <br /> Facilil ,address:2360 W GRANTLINE <br /> TRACY,CA 95376 Reason for Submitting this Form(Check One) <br /> FaciDy Phone#: 209-830-9917 ❑ Change of Designated Operator <br /> ® Update ICC#and/or Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> Primary (Optional) <br /> Designated Operator's Name:Ian Moorhead Relation to UST Facility(Check One) <br /> Business Name(1f different from above):Gilbarco/Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> De-ganated Operator's Phone#:916-947-5285 ❑ Service Technician O Third-Party <br /> International Code Council Certification#: 5250115-UC Expiration Date:10-31-2008 <br /> A1.,T E ATE 1(Optional) <br /> Designated Operator's Name:Jim Palmer Relation to UST Facility(Check One) <br /> Business Name(If different from above):Gilbarco Feeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> Desinnated Operator's Phone#:831-840-5235 ❑ Service Technician © Third-Party <br /> International Code Council Certification#:5254109-UC Expiration Date:02-21-2007 <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Name:Daniel Perez Relation to UST Facility(Check One) <br /> Business Name(If different from above):Gilbarco Feeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> T)P.,i hated Operator's Phone#:916-718-0139 ❑ Service Technician © Third Party <br /> l f national Code Council Certification#:5246161-UC Expiration Date:11-30-2006 <br /> I cei ti.fy that, for the facility indicated at the top of this page,the individual(s)listed above Will <br /> as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> 1 ;by inspections and annual facility employee training,in accordance with California Code of <br /> k y;Ulations,title 23, section 2715(c) - (f). <br /> Pirthermore,I understand and am in complian ' h the uirements (statutes, <br /> regulations,and local ordinances) applicable o der gr n storage tanks. <br /> NAME OF TANK OWNER(PIease Print):7-E - Y MARTIN <br /> S1 GNATURE OF TANK OWNER: <br /> DATE: 11/09/2006 OWNER'S PHONE#: (253) 796-7170 <br /> November 2004 <br />