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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Kaiser Permanente Manteca <br />1777 W. Yosemite <br />Manteca, CA 95337 <br />209.825.3533 <br />Facility ID # <br />Reason for Submitting this Form (Check <br />One) <br />❑ Change of Designated Operator <br />xx Update Certificate Expiration Date <br />Designated UST Operators) for this Facility <br />raeuVlesae I <br />Designated Operator's Name: Keffiiet$ is%Bad" l�IcCusig� <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician XX Third -Party <br />Business Name (If different from above):Petro-Analytical, Inc. <br />Designated Operator's Phone #: 925.253.0591 <br />International Code Council Certification #: 5234516 -UC <br />expiration Date: 11/052012 <br />tu.1 r,nirta 1 r. 1 k v awiaaa <br />Designated Operator's Name:; Tom_Iingston <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician XX Third -Party <br />Business Name (If different from above):Petro-Analytical, Inc <br />Designated Operator's Phone #: 925.253.0591 <br />International Code Council Certification #: 5301063 -UC <br />"ion Dat,:, 11/02f2017 <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)• �jGZGi�eu CSO t^ <br />r 1r / 111AM01 D1' Ma W LIN <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/cgpa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />Please sign this page, then fax to your local agency and to PAI @ 413.832.2427. Thank you. <br />November 2004 <br />