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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name:7-Eleven 32190 Facility ID#:32190 ' FacilityAddress: 4943 Stale Hwy 99 Stockton,CA 95215 Reason for Submitting this Form(Check One) — ® Change of Designated Operator Facility Phone#: (209)939-0679 ❑ Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operators Name: Brian Hernandez Relation to UST Facility(Check One) Business Name(if different from above).Belshim Environmental Services,Inc, ❑ Owner ❑ Operator [] Employee Designated Operators Phone M 949460-5200 ❑ Service Technician E Third-Party — International Cade Council IC #:5308636-UC Expiration Date: 4/6/09 ALTERNATE 1 (Optional) Designated Operator"s Name: refer to backup document Relation to UST Facility(Check One) Business Name(If different from above).refer to backup document _ ❑ Owner [I Operator El Employee Designated Operators Phone*referto backup document ❑ Service Technician E Third-Party International Code Council Certification#:refer to backup document Expiration Date:rarer to backup document ALTERNATE 2 (Optfonal) Designated Operators Name:refer to backup document ;Expiration ation to UST Facility(Check One) Business Name(if different from above).referto backup document Owner ❑ Operator ❑ Employee Designated Operators Phone#:refer to backup document Service Technician E Third-Party ------------------- International Code Council Certification#:refer to backup document Date:refer to backup document Fr the facility indicated at the top of this page, the individual(s) listed above will serve as ST Operator(s) The Individual(s)will conduct and document monthly facility inspectionscility employee training, in accordance with California Code of Regulations, title 23, sectione, I understand and am in compliance with the requirements(statutes, regulations,and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): L/jA_j OA H ti A-.A 7-E({_ 1„u` SIGNATURE OF IANK OWNER: =.-::: DATE: of a y.� OWNER'S PHONE If: 0", )1 4G3- 677(, NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1, 2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.goVIust/contacts/cupa aaVs html. - 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE., November 2004