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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Valero Comer Store#3698 Facility ID#: FA0003709 <br /> Facility Address: 153 E. 11ih Street Reason for Submitting this Form(Check One) <br /> Tracy,CA 95376 X Change of Designated Operator <br /> Facility Phone#:209-832-8815 Cl Update Certificate Expiration Date <br /> Desienated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Donald W.Marcetti Relation to UST Facility(Check One) <br /> Business Name(If different from above): Valero <br /> ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 209-601-2373 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8016976-UC Expiration Date:8/21/10 <br /> ALTERNATE 1 (Option[ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above:Valero ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Sandy Huff Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): Valero ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 559-583-3298 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5300068-UC Expiration Date: 12/08/10 <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER <br /> OR OWNERS AGENT (Please Print): Sandy Huff <br /> SIGNATURE OF TANK OWNER O.(_(L qt�V� <br /> OR OWNERS AGENT: oJJ <br /> DATE: _ III 1 b oes OWNER'S PHONE#: 559-583-3298 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards-ca-gov/ust/contacts/cul2a agys html. <br /> November 2004 <br />