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Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: 7-11 20632 Facility ID#:20632 Facility Address: 4627 DA VINCI DRIVE Reason for Submitting this Form(Check One) Stockton,CA 95207 ® Change of Designated Operator Facility Phone#: (209)952-3543 ❑ Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Michael Holkko Relation to UST Facility(Check One) Business Name(/f different from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ® Third-Party International Code Council Certification#: 8025470-UC Expiration Date: 1/10/2014 ALTERNATE 1 (Optional) Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) Business Name(/f different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document ALTERNATE 2 (Optionaq Designated Operator's Name:refer to the backup document Relation to UST Facility(Check One) Business Name(/f different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c)-(f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations,and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): Stephen K. Boyd SIGNATURE OF TANK OWNER: DATE: 2/6/2012 OWNER'S PHONE#: (714) 771-5484 NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.00v/ust/contacts/cupa agys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004