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FEB -21-2007 09:53 AM <br />P.01 <br />C7 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name:Super Stop Market <br />Facility ddress:290N.Marin Faclitty ID #: <br />aci <br />Reason for Submitting this Form (C <br />Manteca, CA. 95336 X 11 Change <br />of Designated <br />heck ()ne) <br />FacilityPhone #: 20 ;?:t X Change Of Designated Operator <br />Chan <br />at, <br />. Certificate <br />El Update Certificate Expiration Date <br />1101, 1 11 <br />111 <br />PRIMARY IN 1.11ii <br />Designated <br />n <br />Operator's Name: Karen R Aruaiz Relation to UST Facility (Cheek One) <br />— Name: Rr <br />or,"" f <br />;;9 <br />w)" <br />Business Name WdWre-ntfrom above): 1] Own <br />Operator's <br />6 ph #.. 51 er E] <br />Phone <br />I Owner 0 Operator 1) Employee <br />Designated 00crator's Phone a - (209) 518-4836 ] Service <br />'e <br />8 0 Service Technician X ThW.party <br />rt <br />international Code Council Certification #:5266643 - <br />Expiration <br />Expiration Date. 09/12/07 <br />ALTERNATE 10 ,.n <br />Designated Operator's Name! <br />Business Name (1fdiffemntfront above),, <br />Designated Operator's Phone #: <br />International Code Council Certification <br />ALTERNATE 2 (Opdoaaf) <br />Designated OPMtor's Name: <br />Business Name (ffdifferent from above); <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check 0---) <br />• Owner 0 Operator o rimpioyce <br />• Service Technician D Third -Party <br />Expiration Date: <br />Relation to UST Facility (Check One) <br />Ll Owner 0 Operator 13 Employee <br />El Service'rechnician E3 Third -Party <br />Expiration Date: <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 the requirements (statutes, <br />regulations, and local ordi(ances) applicable to underground storage tanks. <br />!NAME OF TANK OWNER (Please Print): C4oeDo2�9 <br />SIGNATURE OF TANK OWNER: <br />7rj7- <br />7P", / <br />DATE: OWNER'S PHONE #. <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 <br />AT: :.,;:".,,,ft/ust/contactslcupa agys.html. <br />• <br />TCAAAGES TO TAIS IAVORMATION WITHIN 30 DAI <br />OF THE CHANGE. <br />November 2004 <br />