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0 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7-11 32190 Facility ID#:32190 <br /> Facility Address: 4943 S. STATE RT. 99 Reason for Submitting this Form(Check One) <br /> STOCKTON, CA 95215 ❑ Change of Designated Operator <br /> Facility Phone#: 2099390679 E Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Justin Downs Relation to UST Facility(Check One) <br /> Business Name(1fdiHerent from above): BBlshire Environmental ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone M (949)460-5200 ❑ Service Technician E Third-Party <br /> International Code Council Certification M 8232225 Expiration Date: 1/3/2016 <br /> ALTERNATE 1 O tional <br /> Designated Operator's Name: refer to the backup document Relation to UST Facility,(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone M refer to the backup document ❑ Service Technician E Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operators Name:refer to the backup document Relation to UST Facility,(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone M refer to the backup document ❑ Service Technician E Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations,title 23, section <br /> 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): Stephen{K. Boyd /j n <br /> SIGNATURE OF TANK OWNER: A� �C <br /> DATE: 1/21/2014 OWNER'S PHONE#: (714) 771-5484 <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 AT: <br /> www.waterboards.ca.gov/ust/contacts/cui)a apes html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />