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S <br /> Owner Statements of Designated Underground Storage Tank UST O 0' <br /> g g g (UST) p�� �i: _ � <br /> and Understanding of and Compliance with UST Requirements �/V�_" v, "OOH <br /> Facility Name: Boyett Petroleum—Kwik Sery Facility ID#: <br /> Facility Address:419 South Main Street Manteca,CA 95366 Reason for Submitting this Form(Check One) S Tti <br /> ❑ Change of Designated Operator <br /> Facility Phone#: (209)239-7978 1 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Rick Jewell Relation to UST Facility(Check One) <br /> Business Name: Boyett Petroleum ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)321-0017 )1 Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different 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(If different 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): D le Boyett <br /> SIGNATURE OF TANK OWNER: &Z, <br /> DATE: r5 d L/ OWNER'S PHONE#: (209) 577-6000 <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 ays.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />