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i� <br />DEC 16 2004 <br />El�V1 Ji"11i tL illi II r'' Ii" <br />Owner Statements of Designated Underground Storage kl'%,- S,�� perator <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 Overator(s) for this Facility <br />PRrTtARv <br />Designated Operator's Name: Pamela Kissick <br />Relation to UST Facility (Check One) <br />❑ Owner ® 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 />ALTERNATE t (0 !ionah <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 />ALTERNATE 2 (Optional) <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 />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: Pamela Kissick as <br />DATE: 12/14/2004 <br />OWNER'S PHONE #: 909-469-2260 <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.eov/ust/contacts/cupa aSysht 1. <br />2$ NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />