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0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: ConocoPhillips Site 255417 Facility ID#: <br /> Facility Address: 1700 EAST YOSEMITE AVE Reason for Submitting this Form(Check One) <br /> MANTECA,CA 95336 X Change of Designated Operator <br /> Facility Phone#:(209)823-7676 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Eric Garcia Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:925-756-1210 ❑ Service Technician d-Party <br /> International Code Council Certification#:5094004-UC Expiration Date: 11/2412006 <br /> ALTERNATE 1 O tlo <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom 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(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST RE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify 0-"at, for she .ciiity indicated at the top cXthis r ��e, th i<.dh �x"(s) list:gid above Agill <br /> serve as Designated UST Operator(s). The individuai(s) will cc�n�,uc� a:ad document mont.ly <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 OWNER'S AGENT(Please Print): Irene Jimenez for Conoco hillil2s <br /> SIGNATURE OF TANK —�� <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 5-19-05 OWNER'S PHO #: 510-245-5176 <br /> San.Joaquin County Environmental Health Dept. <br /> September 2004 <br />