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� )LCEWD <br />JAN 1 0 2005 <br />HEALTH <br />Owner Statements of Designated Underground Storage ' Xw*wator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: VER -Manteca CO <br />Facility ID #: 02154 <br />Facility Address: 430 W. Center Street <br />Manteca CA 95336 <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) 239-0251 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Pamela Kissiek <br />Relation to UST Facility (Check One) <br />❑ Owner IN Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): SunWest Engineering Constructors, Inc. <br />Designated Operator's Phone #: (562) 663-1319 <br />International Code Council Certification #: 5044068 -UC <br />Expiration Date: September 10, 2006 <br />AT TRRNATV 1 in -H-11 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />AL'ILKINAIE L (uptlonai) <br />Designated Operator's Name: <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration Date: <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): Verizon <br />SIGNATURE OF TANK OWNER: <br />DATE: 12/27/04 OWNER'S PHONE #: <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/conitacts/c�uaa_ays t 1. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />