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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#14417 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 Designated UST Operators) for this Facility—PAGE 2 ALTERNATE Designated Operator's Name: Ian Moorehead Relation to UST Facility(Check One) Business Name(Ifdierentfromabove): Gilbarco—VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: 303-986-8011 ❑ Service Technician Third-Party Intemational Code Council Certification#: Expiration Date: 1 ALTERNATE (Optional) Designated Operator's Name: Cindy Padden Larson Relation to UST Facility(Check One) Business Name(Ifdierent from above): Gilbarco-Veeder ❑ 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:Eric Banghart 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: ALTERNATE (Optional) Designated Operator's Name:Rayna Guttman 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: ALTERNATE (Optional) Designated Operator's Name:Blake Hemess 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: 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 the re ements(statutes,regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): Ra d� SIGNATURE OF TAN 70y R: DATE: ��{ OWNER'S PHONE#: 253-796-7170