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Owner Statements of Designated Underground Storage Tank ( <br />and Understanding of and Compliance with UST Requi <br />Kaiser Permanente Manteca <br />James Brakkee <br />1777 W. Yosemite. <br />Manteca, CA 95337 <br />209.825.3533 <br />R�s <br />s° r <br />Qp&/z, <br />'.., ei Ca <br />Facility ID # <br />Reason for Submitting this Form <br />(Check One) <br />xx Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Designated UST Operatorfs) for this Facility <br />Designated Operator's Name: Kenneth W. `Bud' McCuaig <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician XX Third -Party <br />Business Name (If ditfferent from above): Petro -Analytical, Inc <br />Designated Operator's Phone #: 925.528.9998 <br />International Code Council Certification #: 5234516 -UC <br />Expiration Date: 6/22/08 <br />ALTERNATE 1 "Tonal) <br />Designated Operator's Name: Mike Toupin <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician %% Third -Party <br />Business Name (If different from above): Petro-Ana4lica4 Inc <br />Designated Operator's Phone #: 707.217.3399 <br />International Code Council Certification #: 5255746 -UC <br />Expiration Date: 2/02/09 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Thomas Hingston <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician %% Third -Party <br />Business Name (Ifdifferent from above): Petro-Analytica4 Inc <br />Designated Operator's Phone #: 707.295.6066 <br />International Code Council Certification #: 5301063 -UC <br />Expiration Date: 12/28/08 <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 />NAMEE <br />SIGNATURE OF TANK OWNER: A,kL <br />DATE: <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: wwiv.waterboards.ca.pov/ust/(.ontacts/cepa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />