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May X04 11 03:07p Reliable PetroleumA 209-845-8953 p.10 <br />` I) <br />0 0 <br />Owner <br />t <br />'�rJ , <br />:i <br />of Designated Underground Storage Tank (UST) Qperator <br />sanding of and Compliance with UST Requirents <br />Facility Name: SHE L 1-5 <br />Facility ID #: .; J <br />Facility Address: 71 W.8* Street, Stockton CA 95246 <br />Reason for Submitting *6 Form (Check One) <br />Expiration Date: 12-23-2011 <br />Change of Desig�dtet� Qpt rotor' ' <br />i Facility Phone #: 2 939-0961 <br />X Update Certificate Expiration Date <br />prarw auv <br />II Deshmated UST 02erator(s) for this Facility <br />Designated Operator Name: Robcrt Barnhart <br />Relation to UST Facility (Check One) <br />❑ Oar ❑ Operator ❑ Employee <br />X Service Technician D Third -Party <br />Business Name (Ifdi Brent from above): Reliable Petroleum Services Inc. <br />Designated Operator Phone .#: 209-604-9336 <br />international Code C uncil Certification #: 5252540 -UC j <br />Expiration Date: 12-23-2011 <br />Designated Operator Name: Guadalupe Sanchez <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator O Employee <br />X Service Technician 0 Third -Party j <br />Business Name (Ifdi erenl from above):Relrable Petroleum Services Inc. <br />Designated Operator Phone 0: 209-604-9363 <br />International Code C4 uncil Certification #: 5250451 -UC <br />Expiration Date: 01-29-2013 <br />r-'q■7 ■a.g►r.V6&jF illi+moi; <br />Designated Operator Name: <br />Business Name (IM erent from above): <br />Relation to UST Facility (Check One) <br />Q Owner 0 Operator ❑ Employee <br />O Service Technician D Third -Panty <br />Designated Operator Phone #: <br />International Code C uncil Certification #: <br />Expiration Date: <br />I certify that, for :he facility indicated at the top of this Mage, the individuals) listed above will <br />i serve as Designa ed UST Operatm(s). The individual(s) will conduct and document monthly <br />facility inspectio is and annual facility employee training, in accordance with California Code of <br />Regulations} title 23, section 2715(c) - (#). <br />Furthermore, I nderstand and ala in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable undergr nd storage tanks. <br />NAME OF TANK WNER (Please Print): <br />SIGNATURE OF I ANK OWNER; •_ <br />DATE. % OWNER°S PHONE#: <br />MOTE: I) SUBMIT THIS COMPLETED FORINT TO THE LOCAL AGEINCY (NOT THE S'T'ATE WATER <br />RESOURCES CON rROL BOARD) BY JAN[IARY'l, 2001 THE LOCAL AGENCY LIST IS AVAILABLE <br />AT:..._.:,�_}LtS ;rFa�:rr :a. as..;u•>�r_�cit:s:Ei�c �r��zj _t_ <br />- ttr-i i <br />2) NOTIFY THE L CAL AGENCY OF ANY CHANGES TO THIS INFORIMATION WITHIN 30 DAYS <br />OF THE CHANGE <br />