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May 04 11 03:10p Reliable Pe'troleumA 2c)-845-8953 p.15 <br /> Owner St tements of Designated Underground. Storage Tana; (UST) d ator <br /> an Understanding of and Compliance with UST Requirement�� 0 <br /> Facility Name:A-O qE GAS&FOOD Facility 1D#: <br /> 20/1 <br /> Facility Address: 5 W.Grantline Road,Tracy CA 95376 Reason for Submitting tais Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone#: 2 9-833-3416 X Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operato s Name: Robert Barnhart Relation to UST Facility(Check One) <br /> Business Name(If d erent from above):Reliable Petroleum Ser—Inc <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-604-9336 X Service Technician ❑ Thittd-Party <br /> International Code Council Certification#: 5252540-UC Expiration Date: 12-23-2011 <br /> ALTERNATE 1 ( fional) <br /> Designated Operator Name:Guadalupe Sanchez Relation to UST Facility(Check O. ) <br /> Business Name(If d erent from above):Reliable Petroleum Services Inc. <br /> O Owner ❑ Operator ❑ Employee <br /> Designated Operator s Phone Y: 209-604-9363 X Smice Technician ❑ Third-Party <br /> International Code C uncit Certification#: 5250451-UC Expiration Date;O1-29-2013 <br /> ALTERNATE 2 ( fional) <br /> Designated Operator -Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdr Brent from aoove l: <br /> C Owner ❑ Operator ❑ Employee <br /> Designated Operator Phone#: D Service Technician ❑ Third-Party <br /> International Code C unci]Certification t#: Exoiration Date: <br /> i <br /> I certify the ' e fae17 indfi <br /> serve as Desi ted arthe top of this page,the individual(s) listed above will <br /> ed UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspectiand jnima� -lity employee <br /> Regulations, tit] 23,section 2715(c) training, in accordance with California Code of <br /> - ( , <br /> Furthermore,I lmderstand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances)applicable to underground storage tanks, <br /> NAME OF TANK 'MR(Please Pr' P-C��`� <br /> SIGNATURE OF OWNER. <br /> DATE: OWNER'S PHONE <br /> NOTE: 1)SIIBMI TAMS COMPLETED FORM TO THE LOCAL AGENCY <br /> TAT <br /> RESOURCES CO ROL BOARD)BY JANUARY I,2U05.THE LOCAL AGENCYTHE <br /> I STSIS A_E WATER <br /> VAILABLE <br /> AT: www.waterboar s.ca. ov/ust'contactsrcu a as.html. <br /> 2)NOTIFY TETE AL AGENCY OF A,N V CHANGES TO TEAS INFORMATION <br /> OE THE CHANGE 'WI'THiN 30 DAYS <br />