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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7-11 19976 Facility ID: 19976 Facility Address: 1399 N. MAIN ST. — Reason for Submitting this Form (Check One) MANTECA, CA 95336 ■ Change of Designated Operator Facility Phone #: (209) 239-3252 ❑ Updated Certificate Expiration Date — Desi nated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Jhustin Abeleda Relation to the UST Facility (Check One) Business Name (If different from above): Belshire Environmental Services, Inc. ❑ Owner ❑ Operator o Employee Designated Operators Phone #: (949) 460-5200 ❑ Service Technician ■ Third -Party International Code Council Certification #: 8036229 -UC Expiration Date: 912612011 ALTERNATE 1 Designated Operators Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Expiration Date: refer to backup document ALTERNATE 2 Designated Operators Name: refer to backup document Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party I International Code Council Certification M refer to backup document Expiration Date: referto backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s) The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Ian Moorhead Signature of Tank Owner: Date: os%s (2-0.p Owner's Phone #: (916) 463-6776 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 c2 gov/usUcontacts/cupa_agys html 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE