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Il!lay 0-10.11 03:07p Reliable PetroleumA 209-845-8953 p.9 Owner S atements of Designated Underground Storage Tank (UST) Operator Understanding of and Compliance with UST Requirements Facility Name:AlMINI MART 76 Facility ID#: Facility Address: 5775 S.Patterson Pass Road,Tracy CA 95376 Reason for Submitting this Fotiri(C)?�ck One) Change of Designated Operator Facility Phone#: 09-835-7777 X Update Certificate Expiration Date Designated UST a erator s for this Facili - PRIMARY Designated Opera is Name: Robert Barnhart R:lation to UST Facility(Check One) Business Name(1 different from above):Reliable Petroleum Services Inc. ❑ Owner ❑ Operator ❑ Employee Designated Ope is Phone#: 209-604-9336 X Service Technician ❑ Third-Party International Codd Council Certification#: 5252540-UC Expiration Date: 12-23-2011 ALTERNATE 1 O banal Designated Opera is Name:Guadalupe Sanchez =Relationility(Check One) B•asiness Name( different from above):Reliabiepetroleum Services erator ❑ EmployDesignated Oper or's Phone#:209-604-9363 an ❑ Third-Party International Cod Council Certification#:5250451-UC Expiration Date:01-29-2013 ALTERNATE 2 (Optional) Designated Oper or's Name: Relation to UST Facility(Check One) Business Name( differentfrom above): C Ovvner ❑ Operator ❑ Employee Designated Ope or's Phone#: Q Service Technician ❑ Third-Party International C Council Certification#: Expiration Date: I certify that, For the facility indicated at the top of this page,the individual(s) listed above will serve as Desi pated UST Operator(s). The individual(s)will conduct and document monthly facility inspe tions and annual facility employee training,in accordance with California Code of j Regulations, - e 23,section 2715(c) - (f). I Furthermore,f understand and am in compliance with the requirements(statutes, regulations, tld local ordinances)applicable to underground storage tanks. NAME OF TA K OWNER(Please Print):)K SIGNATURE OF TANK OWNER;?X DATE: 04I OWNER'S PHONE#: �G� 7) i NOTE: l)SU 1<IT 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: �.twvM.��atc boards.ca.,ov;'ust'contacts%ct�a agvs.htntl. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHA GE.