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RECEIVED AUG Owner Statements of Designated Underground Storage Tank ( JORRIftTAL HEALTH an Understandingof and Compliance it UST eiremen DEPARTMENT Facility Name: KAISER MANTECA_MC j Facility ID: ANTECA_MC Facility Address: 1777 W.YOSEMITE AVENUE Reason for Submitting this Form(Check One) MANTECA,CA 95336 ■ Change of Designated Operator Facility Phone#: ® Updated Certificate Expiration Date _. A Q sI ted UST Q erator(s)for this Facility PRIMARY Designated Operator's Name: Fredy Barrita Soriano Relation to the UST Facility(Check One) i Business Name(If different from above):: Belshire Environmental Services,Inc 0 Owner 0 Operator U Employee Designated Operator's Phone#: (949)460-5200 D Service Technician ■ Third-Party International Code Council Certification* 8255323 Expiration Date: 4/21/2016 ALTERNATE 1 Designated Operator's Name. refer to backup document Relation to the UST Facility(Check One) Business Name(If different from above). refer to backup document 0 Owner LS Operator ❑ Employee Designated Operator's Phone#: refer to backup document 0 Service Technician ■ Third-Party International Code Council Certification#: refer to backup document i Expiration Date refer to backup document ALTERNATE 2 Designated Operator's Name: r_�_ efer to backup document Relation to the UST Facility(Check One) Business Name(If different from above): refer to backup document ❑ Owner 0 Operator U Employee Designated Operators Phone#: refer to backup document ❑ Service Technician ■ Third-Darty International Code Council Certification#: refer to backup document Expiration Date: refer to backup document I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance With California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. Name of Tank Owner (print): Sam Corbin, on behalf of KAISER FOUNDATIONHOSPITAL Signature of Tank Owner: Date: 5121{2014 Owner's Phone ##: (209) 050-7836 NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE NATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005,THE LOCAL AGENCY LIST IS AVAILABLE AT: vv.�vaterboards.ca.govr`ustcontacts cupa_agys htmi. 21 NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 3€1 DAYS OF THE CHANGE.