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�1N L <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator ' <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:7-Eleven 19976 Facility ID#:19976 <br /> i <br /> Facility Address: 1399 N Main St Reason for Submitting this Form(Check One) – <br /> Manteca,CA 95336 <br /> ® Change of Designated Operator <br /> Facility Phone#: (209)239-3262 ❑ Update Certfficate Expiration Date <br /> i <br /> Designated UST Operator(s) for this Facilitv Lai <br /> PRIMARY <br /> Designated Operator's Name: Brian Hernandez Relation to UST Facility(Check One) <br /> Business Name(If different from above)Belshire Environmental Services,Inc, <br /> ❑ Owner E3 operator [I Employee - <br /> Designated Operator's Phone#: 949-460-5200 ❑ Service Technician ® Third-Party j <br /> i— <br /> International Code Council Certification#:5308636-UC Expiration Date: 4/6109 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator s Name: refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above).refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above) refer to backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to backup document Expiration Date:refer to backup document <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designated UST Operator(s) The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br /> 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 LANK OWNER(Please Print): kt-4.,- <br /> SIGNATURE OF IANK OWNER: <br /> DATE: 1"'�r �_b /0 � OWNER'S PHONE#: 3 - 6 77� <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> www.waterboards.ca.gov/ust/—ContaCtS/CLIPa--a-qys.htmi, <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />