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RECaVED <br /> JAN 2005 <br /> Owner Statements of Designated Underground Storage Tank (UST) r <br /> UI <br /> and Understanding of and Compliance with UST Requirem E NTy <br /> LTH DEFT <br /> Facility Name: Hammer Mini Mart Facility ID#: <br /> Facility Address: 3304 W Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton CA 95219-4593 ■ Change of Designated Operator <br /> Facility Phone#: 209 951-8960 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Eric Wayne Garcia Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): Quest GSM ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (925)756-1210 ❑ Service Technician 0 Third-Party <br /> International Code Council Certification#:5094004-UC Expiration Date: 11/24/2006 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> 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 <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 ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER C k. <br /> OR OWNER'S AGENT(Please Print): J�' <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: 77 <br /> DATE: / t) <br /> wNER's PHONE#: <br /> September 2004 <br />