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Dec 30 04 11:03a 0 p.2 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />FacilityName: <br />1 �. Facility ID #: <br />0.tl)tr. �' .r <br />Facility Address: X39 S }pai}c.-� Reason for Submitting this Form (Check One) <br />Ar Changc of Designated Operator <br />Facility Phone #: `lt) 9 si q = 3-7 1 S ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />rxtmAx r <br />Designated Operator's Name: 0i,, 0\ 3 h <br />Relation to UST Facility (Check One) <br />W Owner ❑ Operator ❑ Employer <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifd perent from above): <br />Designated Operator's Phone #: p 5C)- I s <br />International Codc Council Certification #: <br />Expiration Date: t <br />AL ZKI\HIL 11v mumu ____-.- <br />Designated Operator's Name: moo✓` +(y� et^ <br />Relation to UST Facility (Check One) <br />❑ mer ❑ Operator ❑ Employee <br />Service Technician ❑Third -Party <br />Business Namc(Ifdiffererlrfro nl a bow).' VDatL C C <br />Designated Operator's Phone#: qOG) 537D1 <br />—3A.la <br />International Code Council Certification #: <br />2t -I S 9 y A ` G <br />Expiration Date. I l -1 k - 200 to <br />Designated Operator's Name: "{ 3V, L C3,p n <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />9KService Technician ❑ Tbird-Party <br />Business Name Wdifferenrfrom above): -Oor\ems O <br />Designated Operator's Phone #-], 0 DI 3 -7- S 3 l� <br />International Code Council Certification #: S 2 y 3-15 8 - U C <br />Expiration Date: 10 -:2 -1 --000(, <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 <br />SIGNATURE OF TANK OWNER: <br />DATE: 11- 30 - a.19'pA OWNER'S <br />acA 5q5-3 715 <br />Nnvrmtwr Innd <br />