BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department 304 E. Weber Ave.,Third Floor Stockton CA 95202 Telephone(209) 468-3420 Fax (209) 468-3433 4f4,?,g Owner Statements of Designated Underground Storage Tank (UST) Ootlrator 2011 and Understanding of and Compliance with UST Requirementl�� '_ Facility Name: Valley Pacific Petroleum Fresno Ave Cardlock Facility ID#: r Facility Address: 1524 Fresno Ave Reason for Submitting this Form(Check One) Stockton, CA 95206 [1 Change of Designated Operator Facility Phone#: 209-948-9412 11 Update Certificate Expiration Date Desi2nated UST Overator(s) for this Facility PRIMARY Designated Operator's Name: G. Michael Eliason Relation to UST Facility(Check One) Business Name(If different from above): 0 Owner 0 Operator IN Employee Designated Operator's Phone#:559 732-8381 11 Service Technician 0 Third-Party International Code Council Certification#: 5250416-UC Expiration Date:3/22/2013 ALTERNATE I tional Designated Operator's Name:James Abbott Relation to UST Facility(Check One) Business Name(Ifdifferent from above): 0 Owner El Operator 11 Employee Designated Operator's Phone#:209 601-4641 0 Service Technician 11 Third-Party International Code Council Certification#: 8006067-UC Expiration Date: 3115/2012 ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(Ifdifferentfrom above): [J Owner 0 Operator 0 Employee Designated Operator's Phone#: 0 Service Technician 0 Third-Party International Code Council Certification#: Expiration Date: NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. 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) -(0. Furthermore,I understand and am in compliance with the requirements (statutes, regulations,and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): Mike Eliason SIGNATURE OF TANK OWNER: DATE: 3/22/2011 OWNER'S PHONE#: 209-993-8793 November 2004