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4", <br /> JUN 1 9 2009 <br /> Owner Statements of Designated Underground Storage Tankaj*,. for <br /> and Understanding of and Compliance with UST Re AL'Ty <br /> $ft DEPANMENT <br /> Facility Name:Valero Facility ID# <br /> Facility Address: 1001 E Yosemite Reason for submitting this Form(Check 0.q) <br /> Manteca,CA.95336 X Change of Designated Operator <br /> Facility Phone#(209)825-4569 Update Certificate Expiration Date <br /> Designated UST Operator(g)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(if differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:(209)5184836 0 Service Technician X Third-Party <br /> International Code Council Certification#:5266643-UC I Expiration Date:07/16/09 <br /> ALTERNATE 1 fflpfional) <br /> Designated.Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 13 Owner 0 Operator El Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 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(Odifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: I Expiration Date: <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(Please Print): j4pwj n ij ii.'I 66L <br /> SIGNATURE OF TANK OWNER: 4014 C /Z/69 -- <br /> 1z <br /> DATE:—06/17/09*k3 OWNER'S PHONE#: 460( 97)-9-S US (p:9 <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.cov,,'Ust,'contacts/cuva aays.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> T -Cl d06 :S0 60 ST unr <br />