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o RECEIVEY <br /> NOV 16 2012 <br /> Owner Statements of Designated Underground Storage Tank (USTIA50000NTY <br /> and Understanding of Compliance with UST Requirements ENVIRONMENTAL <br /> Designated UST Oaerator(s)for this Facility HEALTH DEPARTMENT <br /> Facility Name:Manteca.Cheveron Facility ID#: <br /> Facility Address: 1257 W.Yosemite Reason for Submitting this Form(Check One) <br /> Manteca,Ca 95337 X Change of Designated Operator <br /> Facility Phone 209456-1839 ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-972-5087 X Service Technician X Third-Party <br /> International Code Council Certification#:8036233-UC Expiration Date: 1-26-13 <br /> ALTERNATE 1 O <br /> Designated Operator's Name:Josh Brown Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above):Franzen Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 559-688-2977 Service Technician x Third-Party <br /> International Code Council Certification#8171810-UC Expiration Date: 10-22-14 <br /> ALTERNATE 2 (0pdonaQ <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above):Franzen Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-688-2977 X Service Technician XThird-Party <br /> International Code Council Certification#:5311578-UC Expiration Date: 1-26-13 <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 Pry <br /> SIGNATURE OF TANK OWNER <br /> DATE: 1©- -�Z- OWNERS PHONE#: Q <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: am,,q,lw�— <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> �TAVPM�PY 7nnn <br />