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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name:7-Eleven#14117 Facility ID#: Facility Address: 2725 Country Club Blvd. Stockton Reason for Submitting this Form(Check One) ❑ Change of Designated Operator Facility Phone#: 209-463-1259 ❑ Update Certificate Expiration Date DesiEnated UST Operator(s) for this Facility PRIMARY Designated Operator's Name:Daniel Perez Relation to UST Facility(Check One) Business Name(If different from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optional) Designated Operator's Name:Marla Murphy Relation to UST Facility(Check One) Business Name(Ifdii fereni from above): 7-Eleven,Inc. ❑ Owner ❑ Operator ,p Employee Designated Operator's Phone#:925-699-9795 ❑ Service Technician ❑ Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optional) Designated Operator's Name:Robert Clemens Relation to UST Facility(Check One) Business Name(Ifdierent from above): 7-Eleven,Inc. ❑ Owner ❑ Operator yp Employee Designated Operator's Phone#:714-394-6005 ❑ Service Technician ❑ `Third-Party International Code Council Certification#: 5232613-uc Expiration Date:4/23/2006 ALTERNATE (Optional) Designated Operator's Name:Darren Austin Relation to UST Facility(Check One) Business Name(Ifdii ferent from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optionaq Designated Operator's Name:Darryll Riley Relation to UST Facility(Check One) Business Name(Ifdierent from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician Third-Party International Code Council Certification#: Expiration Date: I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training,in accordance with California Code of Regulations,title 23,section 2715(c)-(1). Furthermore,I understand and am in compliance with tL requirements(statutes,regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): an Mart' SIGNATURE OF T K OWNER: DATE: �Z �6 OWNER'S PHONE#: 253-796-7170