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1q:t.5 t-rom:t-HU1L11Y 5tKV1Utb 1 0:dUJqbd54, fl.el Cf <br /> Owner Statements of Designated Undcrgrouvid Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Kai�cr Permanente Manteca Udlity ID# <br /> 1777 W.Yoscmite. Reason for Submitting this.Form(Check <br /> Manteca , CA 95337 One) <br /> 209.825.3533 1 1 Change of Designated 01mrator <br /> xx Update Certificate,Expiration Dale <br /> Designated UST 012cratorLs) for this FaciflU <br /> PRIMARY <br /> Designated Operators Nume: Kennelh W.'Bud'McCuaig Relation to UST Facility(Check Otte) <br /> Ki isineog Name(If dlfferewfrgrn abuvv).-Pc1r&-Ana1ydrA4 Ine, 0 Owner Q Opezatur ri Lrnployev <br /> Designated Operitnr's Phone 0: 925.253.0591 0 ServiceTedmivi-4n XX'Jrhird-Party_ <br /> Intunuttional Codc Council Cenifiration#: 5234516-VC Expiration Dole; 11/05/21112 <br /> L L-7 <br /> ALTERNATE I A!Ltonal) <br /> Cknsignuled Operator's Natnc!'Forn flingston Relation to UST Nvilily((7jeck.One) <br /> Business Nume(If differentfrain abow):lletro-Atwlydeal,Inc 0 Ow,wr n Operator 13 Employer. <br /> Vesignatccl Operator's Plivau 11; 925.253.0591 0 Scrviccfcchnician XX Thiel-Pariv <br /> Infernational Code Council Certitication It:5301063-UC Expiration Wtc: I I/IW2012 <br /> T certify that, for tate;.facility indicated at the top of this pago, the individual(s) I isted above wil I <br /> serve as Designated UST Operator(s). The individual(s) will conduct and document 111onthly <br /> facility inspections and annual facility employev training, in accordance with California Code of <br /> Rugulutions, 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 Pri"QV1 <br /> SIGNATURE OF TANK OWNER: JU <br /> oz L-4 <br /> DATE: - 2A 40 OWNER'S PHONE AW1 <br /> !VOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RF-%(.)ITRCF,S CONTROL BOARD)BY JANUARY I,24M)S.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.witert)oiN,�.c.a,gL)v/UI16LQijtigts/cupa agys.1timl. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES'ro THIS INFORMATION WITHIN 341 DAYS <br /> OF THE CHANGE. <br /> Please sign this page,then fax to your local agency Agd to PAI @ 413.832.2427. Thank you. <br /> November 2004 <br />