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A 1� <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7-11 20632 Facility ID#:20632 <br /> Facility Address: 4627 DA VINCI DRIVE Reason for Submit m(Check One) <br /> Stockton,CA 95207 <br /> ® Change of Desig ;5 , r <br /> Facility Phone#: (209)952-3543 ❑ Update Certificate Expiratio <br /> S YTZ <br /> Designated UST Operator(s) for this Facility 2 0 201, <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to UST Facs. Itz <br /> o- <br /> Business Name(If different from above):Belshire Environmental Services,Inc. [I owner El Operator ElEmp Employee <br /> Designated Operator's Phone#: (949)460-5200 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 8025470-UC Expiration Date: 2/2/2012 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the 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 TANK OWNER(Please Print): Stephen K. Boyd <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 9/13/2011 OWNER'S PHONE#: (714) 771-5484 <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.aov/ust/contacts/cupa aoys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> November 2004 <br />