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05/16/2007 09:44 2095450662 EXP: PAGE 01 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Manteca Express <br /> Facility 1D#- <br /> Facility Address:419 5 Main St Reason for Submitting this Form(Check One) <br /> Manteca CA_95336 X Change of Designated Operator <br /> Expiration Date <br /> Facility Phone#: ❑ Update Certiftcato <br /> I)esignated UST Overat s for this Fa <br /> PRIMARY <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name:Karen R Arnaiz <br /> Business Nano(!f dl/jere.,t from above)' . <br /> ❑ owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 518-41836 <br /> O Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expirntton =09/l2/07 <br /> ALTERNATE I iawa! <br /> F'Lt <br /> Operator's Name: <br /> Relation to iJST Facility(Check One) <br /> ame(ljdi(Jerent jrom above): d Owner ❑ Operator Cl Employee <br /> Operator's Phone#: Q Serice Technician ❑ Third-Party <br /> al Code Council Certification#: <br /> Expiration Date: <br /> ALTERNATE 2 (Opdanad) <br /> Designated Operator's Name: <br /> Relation to UST Facility(Check One) <br /> Rosiness Nmne(!f dif)"erent from abvv¢)• ❑ Owner ❑ Operator ❑ Employee <br /> Desi�tated Operator's Photic#: ❑ Setvitx Technician Q Third-Party <br /> Expiration Date: <br /> lntemational Code Council Certification#: <br /> i certify that, for the facility indicated at the top of this page,the individual(a)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 Califomia Code o£ <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):_ LL—,11 rAdIg%lj(,-/9 % <br /> SIGNATURE,OF TANK OWNER: <br /> DATE: _05/16/07 OWNER'S PHONE#: Z <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.eov/ust/conW#cts/cupa agys.krt j. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE_ <br /> Novernbcr 2004 <br />