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D San'.oaquin County Environmental lea o �( D <br /> o (���� 600 East Weber 1 �1� V <br /> Stockton, CA 95202 Aar 0 7 2010 <br /> ,PR 0 7 2010 <br /> tements of Designated Underground Storage Tan)E TH <br /> ENVIRONM � g RVICES <br /> pERMITISERVI d Understanding of and Compliance with UST Requ <br /> Facility Name: Circle K Store#2701205 Facility ID#: <br /> Facility Address 16470 CAMBRIDGE Reason for Submitting this Form(Check One) <br /> LATHROP,CA 95330 EZ Change of Designated Operator <br /> Facility Phone#:209-858.4116 ❑ Update Certificate Expiration Date <br /> Desilznated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Hakki Alduleme Relation to UST Facility(Check One) <br /> Business Name(If different from above):Same as Above ❑ Owner ❑ Operator 0 Employee <br /> Designated Operator's Phone#: 916-698-7335 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8006061-UC 9/19/2011 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: See Attached List Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> 's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> 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 <br /> OR OWNER'S AGENT(Please Print): Heather Shields Environmental Compliance Coordinator. <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: � Q <br /> DATE: 4/5/2010 OWNER'S PHONE#: 951-270-5193 <br /> September 2004 <br />