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May 04 1.1 02:52p Reliable PetroleumA 209-845-8953 p.4 <br /> • <br /> Owner St tements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Win Country Station Facility ID#: <br /> Facility Address: 1 11 E.Kettleman Lane,Lodi CA 94580 Reason for Submitting this Fors(CheckGre) <br /> Change of Designated Operator <br /> Facility Phone S: 9-369-3633 X Update Certificate,Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operato 's Name: Robert Barnhart Relation to UST Facility(Check One) <br /> Business Name(If ereni from above):Reliable Petroleum Services Ina C Owner ❑ Operator ❑ Employee <br /> Designated Operate 's Phone#: 209.604-9336 X service Technician ❑ Third-Party <br /> International Code ouncil Certification#: 5252540-UC Expiration Date: 12-23-2011 <br /> ALTERNATE t doral <br /> Designated Operas 's Name:Guadalupe Sanchez Relation to UST Facility(Check One) <br /> Business Name(If '`erent tom above).-Reiiable Petroleum Services Irte. C Owner ❑ Operator ❑ Employee <br /> Designated Ope.ato 's Phone#:209.6049363 X Service Technician ❑ Third-Party <br /> International Code ouncil Certification#:5250451-UC Expiration Date:01-29-2013 <br /> ALTERNATF.2 { prionnl) <br /> P <br /> nated Operat 'sName: Relation to UST Facility(Check One) <br /> ess Name(If ' erentfrom above): ❑ Ow-ner Operator ❑ Employee <br /> nated Operat 's Phone#: ❑ Senice Technician ❑ Third-Partyational Code ouncil Certification#: Expiration Date: <br /> I certify that, fo the facility indicated at the top of this page, the individual(s) listed above will <br /> serve as Design'ted UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspecti ns and annual facility employee training, in accordance with California Code of <br /> Regulations,tit 23, section 2715(c)-(f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations, as I local ordinances) applicabl7o underground storage tanks. Y 76) <br /> NAME OF TAN OWNER(Please Print):ClGz- *.tar-t ;VV- <br /> SIGNATURE OF TANK OWNER: <br /> ?� - f —7 <br /> DATE: NE#: �7 <br /> NOTE: 1)SUBMI 7 THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CO 4TROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: �_�y�c,ie aterbo• ds.c:Lg1-rguscc ncrs-cupa html. <br /> 2)NOTIFY THE I OCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANG - <br />