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I b 04 08 12:05p Facility Services (208)825-3895 P.J. <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Kaiser Permanente Manteca <br />1777 W. Yosemite, <br />Manteca, CA 95337 <br />209,825.3533 <br />Reason for Submitting this Form <br />(Check One) <br />xx Change of Designated Operator <br />L-1 Update Certificate Expiration Date <br />Designated UST 012erator(s) for this Facili <br />PRIMARY <br />Designated Operator's Name; Kenneth W. 'bud' McCumig Rclation to UST Facility (Check Onc) <br />Business Name (!fdifferen1from above):Parro-Analylical, Inc. 0 Owner 0 Operator 0 r..Mpjoyce <br />Dmignated Operator's Phone 4, 925.528.9998 0 Service Technician XX Third -Party <br />Ititcmational Code Council Certification #: 5234516 -UC <br />Designated Operator's Name; Thomas 11ingston <br />Business Nanic (ifdiftirenjfrom above):Peyrct-,4najyd,!aj, Inc <br />Dc-signatod Operator's Phone #. 707.295.6066 <br />International Code Council Certification #-. 5301063 -UC <br />Expiration Datc: 6/22/00 <br />Relation to UST Facility ((:beck one) <br />• Owner Li Operator o j-'Mployee <br />• Service Technician XX Third -Party <br />Expiration bate; 12128108 <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). 5 & A K -e- r. 99 <br />SIGNATURE OF TANK OWNER- ( kzw <br />DATE: 2- itlo j OWNER'S PHONE #.- Z -of - PLS- 353 <br />NOTE. 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD). THE LOCAL AGENCY LIST IS AVAILABLE AT: <br />Www. , <br />MaLerboard%-c,.t-onv/iiqt/,-,..ntn,.tI0C ul2a Agy, <br />.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CH1,14GE. <br />Please sign this Page, then fax to your local agency and to PAI (0, 413.832.2427. <br />November 2004 <br />