Laserfiche WebLink
F C <br /> San Joaquin County R L <br /> Environmental Health Department DEC 13 2004 <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> ENVIRONiVIEN] HEALi, <br /> Owner Statements of Designated Underground Storage Tank (USTyCY&fdf6f° 'ICES <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: ZOvis' T Q-AAS 22 Facility ID#: f A OD( 7_'�S' <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> lS C-zIoh d C N 1 ❑ Change of Designated Operator <br /> Facility Phone#: eZo�� 51 i _ o?g o Update Certificate Expiration Date <br /> Desiellated UST Overator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Z- [.Q N o Relation to UST Facility(Check One) <br /> Business Name(IJ different from above):A-C4,,„d T-e r-f- ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#• ?M 57--f_ 1p?7 M-°ervice Technician ❑ Third-Party <br /> International Code Council Certification#: SH /fro css s Expiration Date: 17Z <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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 /> fpr, LoR <br /> , s U-.A•-7 ts ovr c, d' CA, <br /> NAME OF TANK OWNER(Please Print): /-1 cJ-o.-Q <br /> SIGNATURE OF TANK OWNER: & 1 `� <br /> DATE: " Z OWNER'S PHONE#: <br /> CC <br /> C4,S y: o-7 ° November 2004 <br />