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Owner Statements of Designated Underground Storage Tank (US1D�Qpergt2D04 <br /> and Understanding of and Compliance with UST Requir i <br /> ���+s NT HEAL <br /> Facility Name:Beacon Station#3492 Facility ID#: PT0011 3)'' ` <br /> Facility Address:470 N.Main St. Manteca CA 95336 Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone#:209-823-1344 ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Dawn Pernsteiner Relation to UST Facility(Check One) <br /> Business Name(1fafiferentfromabove):Valero Energy Corp X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-614-0085 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 52142—W'7 _ I✓ Expiration Date: 9 L 1 O <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Naveen Khanna Relation to UST Facility(Check One) <br /> Business Name(lfdii ferent from above): Valero Energy Corp ,pt Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-871-3639 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5240963-UC Expiration Date: 9/19/06 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Dennis Smith Relation to UST Facility(Check One) <br /> Business Name(Ifdii erentfrom above): Valero Energy Corp Off Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 559-583-3398 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5230685-UC Expiration Date: 3/20/06 <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 t nderground storage tanks. <br /> NAME OF TANK OWNER(Please Print): 1s ith for tra a Inc. <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/1/04 OWNER'S PHONE#: 559-583-3398 <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.pov/ust/contacts/cupa aevs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />