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M I� <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nasna:Arco <br /> Facility ID#: <br /> Facility Address:1100 S Main St Reason for Submitting this Forth(Check One) <br /> 1vIanteca,CA.95337 ❑ Change of Designated Operator <br /> Facility Phone#:(209)823-6784 X Update Certificate Expiraticm bare <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated OperdLur's Name:Karen R AL'ftBiZ <br /> Relation to UST Facility(Check One) <br /> Business Name({f d�erent from above).• ❑ Owner C] Operator ❑ Employee }k <br /> Designated Operator's Phonc#:(209) 518-4836 ❑ Service Technician li Third-Party <br /> ltttemalioual Code Council Certification#t:5266643-XJC Expiration Date:07/1.6/09 <br /> ALTERNATE l tionai) <br /> Designated Operator's Name: Facility(Check One) <br /> �Relation <br /> Business Name(If different from agave): ❑ Owner ❑ Operator U Employee <br /> #: C7 Service Technician GJ Third-Party <br /> Designated Operator's Phone <br /> ` International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated operator'sName: =OwmerO <br /> (Check One) <br /> Business Name(If di ferent from above): r ❑ �;mployee <br /> Designated Operator's Phone#: ❑ Third-Party <br /> International Code Council Certification#: ` Expiration Date: <br /> I certify that, for the facility indicated at the top of this page,theiztdividual(s) listed above will <br /> serve as Designated"UST Operator(s). The individual(s) will conduct and document zxlonthly <br /> facility inspections and amual facility employee training,in accordance with California Code of <br /> Regulations, title 23, section 2715(e) - (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): _� J C ST 9- <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 08/23/07 OWNER'S PHONE#: �- <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(.NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2045.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www,water oards,ca. ovALsL con acts!c a mvs.htn�l. <br /> 2)NOTIFY TH.E LOCAL AGENCY OF A.NY CHANGES 70 THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />