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0 0 _-) <br /> I r' <br /> Owner Statements of Designated Underground Storage Tank ehator <br /> and Understanding of and Compliance with UST Requireroggts 7 2004 <br /> Facility Name:Valero Station#3641 Facility ID#: FAWOft s,l , ;�, i <br /> Facility Address: 1210 E.Hammer Ln. Stockton CA 95210 Reason for Submitti g fli4 ( oiyxi�{' It:One) <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209447-3111 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Dawn Pernsteiner Relation to UST Facility(Check One) <br /> Business Name(If different from above):Valero Energy Corp 00 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-614-0085 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: EJ 2-4?_ 7- s)Q Expiration Date: /g t OC. <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Naveen Khanna Relation to UST Facility(Check One) <br /> Business Name(If different from above): Valero Energy Corp ® Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-871-3639 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5240963-UC Expiration Date: 9/19/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Dennis Smith Relation to UST Facility(Check One) <br /> Business Name(If different from above): Valero Energy Corp X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-583-3398 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5230685-UC Expiration Date: 3/20/06 <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(Please Print): Muni m' h f r UI m 61C. <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/1/04 OWNER'S PHONE#: 559-583-3398 <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:www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />