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nn <br /> Owner Statements of Designated Underground Storage Tank (UST) Operatbr <br /> and Understanding of and Compliance with UST Requirets 7 2004 <br /> Facility Name:Valero Station#3698 Facility ID#: F Pl: ^�/'il T' <br /> Facility Address: 153 E.11'" St. Tracy CA 95376 Reason for Submi i '('CHe IFQne) <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-832-8815 ❑ Update Certificate Expiration Date <br /> Desienated UST ODerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Dawn Pernsteiner Relation to UST Facility(Check One) <br /> Business Name(If different from above):Valero Energy Corp 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-614-0085 [1Service Technician ❑ Third-Party <br /> Intemational Code Council Certification#: 521{P'�7 —OC, Expiration Date: 0112 I 06 <br /> ALTERNATE/ (Option( <br /> Designated Operator's Name: Naveen Khanna Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): Valero Energy Corp 3 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-871-3639 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5240963-UC Expiration Date: 9/19/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Dennis Smith Relation[o UST Facility(Check One) <br /> Business Name(If different from above): Valero Energy Corp Z Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-583-3398 ❑ Service Technician ❑ Third-Party <br /> Intemational Code Council Certification#: 5230685-UC Expiration Date: 3/20/06 <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) - <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(Please Print): Den m' It for UI a n <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/1/04 OWNER'S PHONE#: 559-583-3398 <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 sov/ust/contacts/cuoa aeys html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />