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FACTUIrY NAME <br /> Manteca KWIK Sery <br /> ctTv <br /> FAcaITY srrE;ADDREss824 E. sernite Ave <br /> REASON FOR SMITI'I[JG MIS FORM(Chrck OneJ� <br /> C37rmge of Designated Operator ®Upd of LCL Ccrdfieation Expiration Dates) <br /> PRIMARY DESIGNATED UST OPERATOR FOR TRIS FACILITY u r-aTIOT TO UST FACILITY(Cheat On) <br /> DEsIGNAro)OPERATORNAMO' Alex Jabbafi �] OWne: ❑ opctator ❑ Employee <br /> BusutESSNnMs(fr "1^aar6" ): Norcal Few0leU(17 Services. Inc ❑ ServiccTechniciao ® Thirl-Perty <br /> DESIGNATED OPERATOR PHONE: (925)389-1262 �• . <br /> INTEaNATIONAL CODE COUNCIL.CERTIFICATION NO-: <br /> 5243$97UC EXP1aA'1TONDATE; 10/6/2014 <br /> ALTERNATE 1 DESIGNATED UST OPERATOR FOR THIS FACILITY RELATIOf'7opetor <br /> sr FACll.1TY(Check One) <br /> DESIGNAI'EDOPERATORNAM: ❑ Employee <br /> BUSIESS NANO(fd&-Nf—above): ❑ SavirAminim ® Third-Party <br /> DESIGNATED OPERATOR PHONE: ( x' EXI'1RAT[ ATE; <br /> INTERNATIONAL CODE COUNCIL.CERTIFICATION NO.: <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR TffiS FACII STY(opdeadl RFLAT1ori•PO UST FACILITY PwckOre) <br /> DESIGNATEDOPECATORNAbfE: ❑ Owner ❑ Operator ❑ Employee <br /> SUSINPSS NAME(1J'diJJsnat/roa abow)� ❑ $Crvµ.c Technician ❑ r - y <br /> DESIONATEDOPERATORPHONE: ( ) exL . <br /> EXPiRATl0N DA <br /> INfEtNATIONAL CODE Cp1JNCIL CF'1C11FICATION NO,: ., <br /> ALTERNATE 3 DESIGNATED UST OPERATOR OR THIS FAC1I ITY(owfiv d) RELATtO.I To UST FACILITY(CkecA6w) <br /> DOSIGNA'I'F.'D OPERATOR NAME: Owner ❑ Operator ❑ Employee <br /> BUSINFBSNME,(1fV9nruf+a"abi )- [ ❑ Third-Party]): Service Technician <br /> DESIGNATED OPERATOR PHONE: <br /> EXPIRATION DATE: <br /> INTER AXIONAL CODE COUNC (•FR--CATION NO.: <br /> I certify that, for the facility iud'icated at the top of this page, the indlviduaspe listed above will serve as Designated training UST <br /> Operator(s). The individual(s)will conduct and document monthly facility inspections and annual faellI employee training <br /> in accordance with California Code of Regulations,Tit*23,Section 2715(1)through (f)• Furiehermore I understand and am <br /> in compliance with the requiroments(Statutes,regulations,and lata,ordinances)applicable to underground storage tanks. <br /> TANROWNERNAIvIE: f 14,61 <br /> oWr7F,1z�1i;nN�: 2c�t) ,'2�1 —2c)Iq <br /> TANKOWNU 1�1' <br /> TANK OWNER SIGNATUIRI;4ISTRUCTIONS <br /> 1. Report the name(s)of the Desigmited UST Operator(s)as registered with the Intemational Codi:+Council(ICC),ICC mrt fioation <br /> information is available on-line at:www,iccsafe orWoJeertseeteh•htmL Search for"California DIST System Operators." <br /> 2. inform this sao available <br /> form to t: local agency that regulates this facility's USTs. Undoes imember agency jurisdictions and <br /> contact this Completed <br /> are listed on-line at: www.undtmorgvmembcWwhoregulateswhat.htaul. Contact iailormation for other <br /> infortuation <br /> local agemies within California <br /> allif rni is available <br /> l agency f any ohangesotn this inlormauon wn'hm 30 days Of'the date of change. <br /> 3. 23 CCR§2715(a)req Y the locag <br /> 0412ras <br /> www.adtlac€orS <br /> UN-662.111 <br /> RECEIVED <br /> JUL 01 2014 <br /> ENVIPONM TAL HEALTH <br />