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M� <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Arco Facility 1D#: <br /> Facilit)r Address:i 100 S Main St Reason for Submitting this Form(Check One) <br /> Manteca,CA,95337 ❑ Change of Designated Operator <br /> Facility Phone#:(209)825-6784 X Update Certificate Expiration Date <br /> Deskmated LIST 4 erator s f r this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Naive(If differeni from above): C.J Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 518-4836 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC Expiration Date.07/16/09 <br /> ALTERNATE 1 tt'onaC <br /> Designated Operator's Name: Relation to UST Facility(Check Orae) <br /> Business Name(lf different from above): ❑ Owner ❑ Operator ❑ Employee <br /> vesignated Operator's Phone#: ❑ Service'Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date <br /> ALTERTNATE 2 (Optional) <br /> Designated Operntor's Name: Relation to UST Facility(Check One) <br /> Business Name(If"different from above): D Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 'Third-Party <br /> International Code Council Cortification#: Expiration Datc: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above VAIl <br /> serve as Designated TEST Operator(s). The individuaI(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, Y 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 S G Ki-Te l`Q P, <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 08/23107 OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)13V JANUARY 1,2045.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: a%wv✓_waterboards.cao�:/ust;cont tsicupa af�°ys.html. <br /> 2)NOTIFY THF LOCAL AGENCY OF ANY CHANCES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />