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FACILITY NAME FACILITY PHONE <br />MaatecaCO, (209)239-0251 <br />FACILITY 91,TE.ADDRE$S- CITY <br />430 W. Center Street Manteca <br />REASON FOR SUBMITTING THIS FORM (Check One): ❑ Change of Designated Operator ❑ Update of ICC Certification Expiration Date(s) <br />PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Bussiness Name (ydifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: ❑ Service Technician ❑ Third P <br />International Code Council Certification #: Expiration Date: <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY (Optional) <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Bussiness Name afdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br />Desij2ated Operator's Phone #: ❑ Service Technician ❑ Third Party <br />International Code Council Certification #: Expiration Date: <br />