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N 0 V 2 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST RequiremsfftS)o1.,,,,Gj,,,uuuK, <br /> IeiUfica(iii 1l TAL <br /> - <br /> Facility Name: 7-11 32262 Facility ID#:32262 IT <br /> Facility Address: 2360 W.Grant Line Rd. Reason for Submitting this Form(Check One) <br /> Tracy,CA 95376 E Change of Designated Operator <br /> Facility Phone#: (209)830-9917 El Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Justin Downs Relation to UST Facility(Check One) <br /> Business Name(If different from above):BeIshire Environmental Services,Inc. [I Owner [I Operator M Employee <br /> Designated Operator's Phone#: (949)460-5200 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: 8021990-UC Expiration Date: 12/712012 <br /> ALTERNATE I (Optional) <br /> Designated Operators 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 El operator El Employee <br /> Designated Operator's Phone#:refer to the backup document El Service Technician 0 Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (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 171 Operator E] Employee <br /> Designated Operator's Phone#:refer to the backup document 0 Service Technician Z 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: 140AIG, AV-10, <br /> DATE: 11/15/2011 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.gov/ust/contacts/cupa agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />