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k � <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:ConocoPhillips Site 255417 Facility ID#: <br /> Facility Address: 1700 E YOSEMITE AVE Reason for Submitting this Form(Check One) <br /> MANTECA,CA 95336 X Change of Designated Operator <br /> Facility Phone#:(209)823-7676 ❑ Update Certificate Expiration Date <br /> Designated UST Oaeratorf s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Chris Amaral Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#:(209)549-2376 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:XX4141013662 Expiration Date: 12/16/2006 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 to underground storage tanks. <br /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Stephen Boyd for ConocoPhillips <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: J-4ok" &v� <br /> DATE: 12/16/2004 OWNER'S PHONE#: 714-428-6572 <br /> San Joaquin County Dept. of Health <br /> September 2004 <br />