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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 7 -ELEVEN #19976 <br />Facility ID #: 235090 <br />Facility Address: 1399 N MAIN <br />Reason for Submitting this Form (Check One) <br />MANTECA, CA 95336 <br />❑ Change of Designated Operator <br />® Update ICC # and/or Expiration Date <br />Facility Phone #: 209-239-3252 <br />Designated UST Operator(s) for this Facility <br />Primary (Optional) <br />Designated Operator's Name: Ian Moorhead <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (If different from above): Gilbarco/Veeder-Root <br />Designated Operator's Phone #: 916-947-5285 <br />International Code Council Certification #: 5250115 -UC <br />Expiration Date: 10-31-2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Jim Palmer <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician !] Third -Party <br />Business Name (If different from above): Gilbarco Veeder-Root <br />Designated Operator's Phone #: 831-840-5235 <br />International Code Council Certification #: 5254109 -UC <br />Expiration Date: 02-21-2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Daniel Perez Relation to UST Facility (Check One) <br />Business Name (If different from above): Gilbarco Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: 916-718-0139 ❑ Service Technician El Third -Party <br />International Code Council Certification #: 5246161 -UC Expiration Date: 11-30-2006 <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 th equirements (statutes, <br />regulations, and local ordinances) applicab to}tnder ound,storage tanks. <br />NAME OF TANK OWNER (Please Print): 7-E C Y MARTIN <br />SIGNATURE OF TANK OWNER: <br />DATE: 11/09/2006 OWNER'S PHONE #: (253) 796-7170 <br />November 2004 <br />M� <br />