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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 /> Facility Name: VALI.CX SCAVIOc STA 710W Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 16 E. #,+Abttv4 WAY, STOCK�t�Nr CA7KZO Y, ❑ Change of Designated Operator <br /> Facility Phone#: (20 &�6 6 .S(& ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Kla 1z t N R. f lk pj A l Z Relation to UST Facility(Check One) <br /> Business Name(If different from above): -� Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (zO 4) 57Jt g_ LjE_3G Service Technician ❑ Third-Party <br /> Intemational Code Council Certification#: Z _ C Expiration Date: ZO�ZC') I <br /> ALTERNATE 1 O banal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom 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(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> Intemational 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 /> NAME OF TANK OWNER(Please Print): #443994 t4441( CIAVS <br /> SIGNATURE OF TANK OWNER: /4• <br /> DATE: oylvrlo OWNER'S PH NE#: (20?)066_?S g <br /> November 2004 <br />