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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Valero Corner Store #3641 <br />Facility ID #: FA0003730 <br />Facility Address: 1210 Hammer Lane <br />Stockton, CA 95210 <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-477-3111 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Donald W. Marcetti <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator X Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): Valero <br />Designated Operator's Phone #: 209-601-2373 <br />International Code Council Certification #: 8016976 -UC <br />Expiration Date: 8/21/10 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator X Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above: Valero <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Sandy Huff <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator X Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): Valero <br />Designated Operator's Phone #: 559-583-3298 <br />International Code Council Certification #: 5300068 -UC <br />Expiration Date: 12/08/10 <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 <br />OR OWNERS AGENT (Please Print): Sandy Huff <br />SIGNATURE OF TANK OWNER <br />OR OWNERS AGENT: <br />DATE: ® /C)rj OWNER'S PHONE #: 559-583-3298 <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 />November 2004 <br />