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0 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facili!y Name: Pacific-Mini-Mart Facili #: FA0002480 <br /> Facility Address: Reason for Submitting this Form (check one) <br /> 4511 Pacific Ave M Change of Designated Operator <br /> Stockton, Calif. 95207 ❑Update Certificate Expiration Date <br /> Facill Phone #: (209)473-1177 L <br /> Designated LIST Operator(s) for this Facility <br /> Primary <br /> Designated Operators name: Dan McIlrath Relation to UST Facility(check one) <br /> Business Name: Valley Under round Tank Monitoring -E]Owner ❑Operator ❑Employee <br /> Designated Operators Phone #: (209)476-1805 1:1 Service Technician X3 Third-eaqy <br /> International Code Council Certification #:XX4141012575 lExpiration ate: 11/13/2006 <br /> Alternate I <br /> Designated Operators name: Relation to UST Facility(check one) <br /> Business Name: ElOwner ❑Operator OEmployee <br /> Desi Inated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification #: Ex2iration Date: <br /> Alternate 2 <br /> Designated Operator's name: Relation to LIST Facility(check one) <br /> Business Name: EJOwner ❑Operator ElEmployee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-paq <br /> International Code Council Certification #: I Ex2iration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS 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 serve as <br /> Designatd 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, <br /> title 23, section 2715 (C)-(F). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, regulations, <br /> and local ordinances)applicable to underground storage tanks. <br /> Name of Tank Owner <br /> or Owners Agent(Please Print): <br /> Signature of Tank <br /> Owner or Owners Agent: <br /> Date: 12-15-2004 Owner's Phone#: <br />