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0 9 <br /> Owner Statements of Designated Underground Storage Tank (UST) <br /> Operator and Understanding of and Compliance with UST requirements <br /> Facility Name: 7-ELEVEN SITE#32190 Facility ID#: 235419 <br /> Facility Address: 4943 S STATE RTE 99 Reason for Submitting this Form(Check One) <br /> STOCKTON,CA 95215 0 Change of Designated Operator <br /> Facility Phone#: 209-939-0679 ❑ Update ICC#and/or Expiration Date <br /> Desi.2nated UST Operator(s) for this Facility <br /> Primary O banal <br /> Designated Operator's Name: Ryan Wyatt Relation to UST Facility(Check One) <br /> Business Name(Ifdiffmntfrom above):Gilbarco Veeder--Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-999.2301 ❑ Service Technician OO Third-Party <br /> International Code Council Certification#: 5315333-UC Expiration Date: 7/23/2009 <br /> ALTERNATE 1(Opdonal) <br /> Designated Operator's Name:SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(If dierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician O Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(Ifdifjerentfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: - - ❑ Service Technician ® Thkd*mty- - <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,the individual(s)listed <br /> above will serve as Designated UST Operator(s). The individual(s) will conduct and <br /> document monthly facility inspections and annual facility employee training, in <br /> accordance with California Code of 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): 7-Eleven Inc.—Ian Moorhead <br /> SIGNATURE OF TANK OWNER: ��— <br /> DATE: 12/17/2008 OWNER'S PHONE#: 916-463-6776 <br /> November 2004 <br />