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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:Manteca Express Facility ID#: <br /> Facility Address:419 S Main St Reason for Submitting this Form(Check One) <br /> Manteca,CA.95366 ❑ Change of Designated Operator <br /> Facility Phone#: X Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: Karen R Arnaiz Relation to USI'Facility(Check One) <br /> Business Name(if different from above): ❑ Owner O Operator ❑ Employee <br /> Designated Operator's Phone#:(209)518-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date:07/16/09 <br /> ALTERNATE I O liana! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lfdii eren!from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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): i 17 <br /> SIGNATURE OF TANK OWNER: k � d'14 4 <br /> DATE:_08/23/07 OWNER'S PHONE#: 2� 52-9 2-- <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: ww%v.watet_hoards.ca.(-,ov'ust%contacts:'c:upa 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 /> T 'd 0990-9SS-60Z -4e2ueW Rqqog eS2 :60 GO as jeW <br />