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, May 04 11 03:07p Reliable Petroleu 20 -845-8953 p.9 Owner S atements of Designated Underground Storage Tank (U$) erator Understanding of and Compliance with UST Requirem , s,y FacilityName: A MINI MART 76 Facility iD #: Facility Address: 5775 S. Patterson Pass Road, Tracy CA 95376 Reason for Submitting this F oe ck One) Change of Designatp4 Qperator 2011 X Update Certificate Expii €itlan Date Facility Phone #: 04-835-7777 Designated UST Olperatorfs) for this Facility ' PRIMARY Designated Op is Name: RobertBarnhart R;lation to UST Facility (Check One) Business Name Q,)different from above): Reliable Petroleum Services Inc. ❑ Owner ❑ Operator 0 Employee Designated Op is Phone #: 209-604-9336 X Service Technician ❑ Third -Party InternatioDalCodi Council Certification #: 5252540 -UC Expiration Date: 1223-201 I AL t•Iw"A' E A Designated Opera v anal or's Name: Guadalupe Sanchez Relation to UST Facility (Check One) p Owner ❑ Operator ❑ Employee X Service Technician a Third -Party Business Name ( dierent from above). -Reliable Petroleum Services Inc. Designated Opera is Phone#: 209-604-9363 International CodR Council Certification #: 5250451 -UC Expiration Date: DI -29-2013 ALTERNATE 2 1 (Optaond) Designated Open or's Name: Relation to UST Facilit-y (Check One) Business Name (dierentfrom above): C Owner 11 Operator 0 Employee Designated Op r`s Phone #: Q Service Technician a Third -Party Intemational Council Certification #: Expiration Date: I certify that, or the facility indicated at the top of this page, the individual(s) listed above will serve as Desi ted UST Operator(s). The individual(s) will conduct and document monthly facility inspe tions and annual facility employee training, in accordance with California Code of Regulations, ' e 23, section 2715(c) - (f). Furtliermo , I understand and am in compliance with the requirements (statutes, regulations, nd local ordinances) applicable to underground storage tanks. NAME OF TA qK OWNER (Please Print): 1 1 9 P '�s—' SIGNATURE OF TANK DATE:—D 11 CM OWNER'S PHONE #: ?) NOTE: 1) SU �o?ard7s;,ca.,—,oyi'usYcontacts,'c-tii)a rr THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCESOL BOARD)13Y JANUARY 1,2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.wate agaWs.htmi. 2) NOTIFY TIE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHA GE.