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May 04 11 03;10p Reliable PetroleumA 209-845-8953 p.14 Owner S& ternents of Designated Underground Storage Tank. (UST) 60eptor anc Understanding of and Compliance With UST Requirements Facility Name:SB c Iks&MART Facility Address: 51 W. Ilei Street,Tracy CA 95376 Facility ID#: Reason for Submitting this Form(Check One} Faciiiiy Phone#: 2 " 48838 Change of Designated Operator X Update Certificate Expiration Date Desi nated UST O rator s for this Facilitv PRIMARY Designated Operator' Name: Robert Barnhart Re�ation to UST Facility(Check One) Business Name(If di rent from above):Reliable Petroleum Services Inc. Designated Operator' Phone#: 209-604-9336 ❑ Owner ❑ Operator c Employee X Service Technician ❑ Third-Party International Code C ncil Certification g: 5252580-UC Expiration Daze: 12-23-2011 ALTERNATE 1 O ona� Designated Operator' Name:Guadalupe Sanchez Relation to UST Facility(Check One) Business Name(1f di rent from above):Reliable Petroleum Services Inc. Designated Operator' hone#:209-604-9363 ❑ Owner ❑ Operator ❑ Employe. X Service Technician ❑ Third-Party International Code Co nciI Certification#:5250451-UC Expiration Date:OI-29-2013 ALTERNATE 2 (Op onal) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If di ent from above}: O Owner ❑ Operator ❑ Employee Designated Operator`s hone#: ❑ Service Technician ❑ Third-Party International Code Cot ncil Certification#: Expiration Date: I certify that, for 1he facility indicated at the top of this page, the individual(s) listed above witl ~ serve as Designated UST Operator(s). The individual(s)Will conduct and'document monthly facility inspectio and annual facility employee bmini Regulations,title 3, section 2715(c) in accordance With California Code of Furthermore,I I nderstand and am in compliance with the requirements (statutes, regulations, and ocal ordinances) appli ble to underground storage tanks. NAME OF TANK 0 WNER(Pleas.P . t � SIGNATURE OF TANK OWNER: i DATE. �J� 1 OWNER'S PHONE :'NOTE: I)SUBMIT HIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CON ROL BOARD)BY AT: .,. JANUARY t'2005.THE LOCAL AGENCY LIST IS AVAILABLE iit'i. `'.'.:.'.'._'�� . 1,C; __•_..o,,•'rU�.�i�•:rit_i]CL -...__ 2)NOTIFY THE AL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHfN 30 DAYS OF THE CHANGE.