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Owner Statemenf Designated Underground Stone Tank (UST) Operator and Unders ding of and Compliance with US equirements Facility Name: Facility Address: 7-11 20632 4627 DA VINCI DRIVE STOCKTON, CA 95207 Facility ID: 20632 Reason for Submitting this Form (Check One) ■ Change of Designated Operator ❑ Updated Certificate Expiration Date _ Facility Phone #: (209) 952-3543 Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Brian Hernandez Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): Belshire Environmental Services, Inc. Designated Operator's Phone #: (949) 460-5200 International Code Council Certification #: 5308636 -UC Expiration Date: 4/6/2009 ALTERNATE 1 Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Expiration Date: refer to backup document ALTERNATE Designated Operator's Name: refer to backup document Relation to the UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): refer to backup document Designated Operator's Phone #: refer to backup document International Code Council Certification #: refer to backup document Expiration Date: refer to backup document 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 (print): Signature of Tank Owner: .17 Date: _ 0// Owner's Owner's Phone #: 91� 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.gov/ust/contacts/cupa_agys.htmi. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE.