COMPLIANCE INFO_2004-2007 - Laserfiche WebLink

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. f Owner Statements of'Designated Underground Storage 'Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7-Eleven#32190 Facility ID#: Facility Address: 4943 S. State Route 99, Stockton Reason for Submitting this Form(Check One) ❑ Change of Designated Operator Facility Phone#: 209-939-0679 ❑ Update Certificate Expiration Date Desitnated UST Operator(s) for this Facility PAGE 2 ALTERNATE Designated Operator's Name: Ijohead Relation to UST Facility(Check One) Business Name(Ifdierentfroilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone# 8011 ❑ ServiceTechniIntemational Code Council CerExpiration Date: ALTERNATE (Optional) Designated Operator's Name:Cindy Padden Larson Relation to UST Facility(Check One) Business Name(If dii ferent from above): Gilbarco-Veeder ❑ Owner ❑ Operator El Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician N Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optional) Designated Operator's Name:Eric Banghart Relation to UST Facility(Check One) Business Name(Ifdii Brent from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator El Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician A Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optional) Designated Operator's Name:Rayna Guttman Relation to UST Facility(Check One) Business Name(Ifdiffereni from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician � Third-Party International Code Council Certification#: Expiration Date: ALTERNATE (Optional) Designated Operator's Name:Blake Hemess Relation to UST Facility(Check One) Business Name(Ifdii ferent from above): Gilbarco-VeederRoot ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:303-986-8011 ❑ Service Technician Third-Party International Code Council Certification#: Expiration Date: Ffy that, for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated perator(s). The individual(s)will conduct and document monthly facility inspections and annual facility yee training,in accordance with California Code of Regulations,title 23,section 2715(c)-(f). ermore,I understand and am in compliance with there uiements(statutes,regulations,and local nces)applicable to on storage tanks. NAME OF TANK OWNER(Please Print): y Martin SIGNATURE OF TANK O R: DATE: z �. D OWNER's PHONE#: 253-796-7170