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10/29/2010 10:12 2092394550 MANTECA LIQUOR FOOD PAGE 01/02 <br /> Owner Statements of Designated Underground Storage Tank(UST)Opar 8 2010 <br /> and Understanding of and Compliance with UST Requirements <br /> "My <br /> Ferny Name_Manteca Liquor and Food FadBq m#: . <br /> kaauty Address 890 N_ Main Street, Manteca, CA Reason for Subnukft this Form(Chock One) <br /> Facility Phone#- 209-239-4550 ❑ Chaw of1 OpGatu <br /> R Update Cert ate Expiratimt Datc <br /> Designated UST Onetratortsl for this Facility <br /> PRIMARY <br /> jDesWm1ed Operator's Name:Alex JabbaA Relation to UST Facility(rheck ow) <br /> usmess Name(ydifferemfwm abow):NenawlPerro&rprtSerVkeler ❑ O�. 0 operator ❑ Employ= <br /> bmgwrted Operator's Phone#: 92SV!P-1261 X ServiceTo'haician ❑ Third-Party <br /> krtrertmonal Code Council Certification#:52.4MW-UC Expiration Dam 10102/2012 <br /> ALTERNATE( <br /> Designated Operabor's Name: Relation to UST Faci V(Check Ow) <br /> Puumew Name(If dokvntfro abrnte): ❑ Owner 0 OKTuh r ❑ Employee <br /> Peoggated Opuetior'sPhone#: ❑ Service Teelntaamm 0 Thiard-Party, <br /> bo,terazd to al Cade Cameil CatiSestion#; Expiration Date: <br /> iALTMA,TE 2 (Opaond) <br /> eesigpffied Operator's Name: Relation to UST Facility(Check One) <br /> P-usinen Name(tjdif midfree.abore): 0 owner ❑ Operator 0 Employee <br /> "gpated Opermor's Phone#: ❑ Service Tcohuicim ❑ Third-Patty <br /> international Code Council Certificatim#: Expiration Date: <br /> i <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 tram mg,im accordance with Califoruia Code of <br /> llkcgulations,title 23,section 2715(c)-(f)_ <br /> Furthermore,)understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> ER <br /> NAME OF TANK OWN (Please Prost). (SA R D T 5 ,7J/J�� <br /> SIGNATURE OF TANK OWNER: <br /> .PDATE:/° "�g 1 OWNER'S PHONE#: <br /> I <br /> NOTE;1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RES )URCIIaS CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LEST IS AYAH ABLE <br /> AT. ..s'w.Barer ors ie.ca..a ts;'u,Vrorracrs cu as ae�e.t.tm <br /> NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS UODRMATDON WITIHN 30 DAYS <br /> bF THE CHANGE. <br /> November 2004 <br />