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• i <br /> Owner Statements of Designated Underground Storage Tank (UST)Op`ratdr ` <br /> and Understanding of and Compliance with UST RequireRfeats 7 2004 <br /> Facility Name:Valero Station#3698 — Facility ID#: F <br /> Facility Address: 153 E. 1P" St. Tracy CA 953 6 Reason for Submit i /iene) <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-832-8815 ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name:Dawn Pernsteiner Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above):Valero Energy Corp la Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-614-0085 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5242387 _01Z� Expiration Date: q/2 l O(, <br /> ALTERNATE I(Option <br /> Designated Operator's Name: Naveen Khanna Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): Valero Energy Corp 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 to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): Valero Energy Corp N Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-583-3398 ❑ Service Technician ❑ Third-Party <br /> International 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-facilityemployee 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(Please Print): Den h V!!t 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.gov/ust/contacts/cupa <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />