Laserfiche WebLink
9 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:ConocoPhiflips 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 0 Update Certificate Expiration Date <br /> Designated UST Aerator s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Eric Garcia Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:925-756-1210 0 Service Technician .0 Third-Party <br /> International Code Council Certification#:5094004-UC Expiration Date:11/24/2006 <br /> ALTERNATE I(Optional) <br /> Designated Operator's <br /> s Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 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(ydifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Ph-one#: 0 Service Technician El Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OFT CHANGE. <br /> I certify that, for t' .frz-31ility ",idicated at v tc-p o; his i----,div* �!"al( 'i t d above will <br /> serve as Designated UST Operator(s). Tilein''ividual(s) 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 OFT OWNER <br /> OR OWNER'S AGENT(Please Print): Irene Jimenez for ConocoPhillips <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 5-19-05 OWNER'S PHONE#: 510-245-5176 <br /> San Joaquin County Environmental Health Dept. <br /> September 2004 <br />