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-J4N-06-2005-THU 12:37 PM P. 004 <br /> i'-- 1.0 <br /> Dec 22 04 03:59p Franzen Hill 5596081467 P•3 <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 /> J FacilityHame: Rancho San Mi uel Lodi FaclitytD#: N-5016 <br /> FacilityAddress'618 Cherokee Reason for Submitting this Form(Check One) <br /> Lodi, CA J( Clunge of Designated Operator <br /> Facility Phone#- (209) 339-8200 ❑ Update Certificate Fxpirefion Date <br /> Desienated UST Overator(s)for this Facility <br /> PRIMARY <br /> Designated Operatur's Name: Franzen- ill Relation to UST Facility(Check Ore) <br /> Business N.=(rfdiff.mnrfrom above): ❑ Owns ❑ Operator ❑ Employce <br /> Desigoatod Operatar's phone#: 559-688-2977 0 Service Teehoician Of Third-Parry <br /> Inteaational Code Council Certification#: 5246124—UC Expiration Date: 11-19—D6 <br /> ALTERNATE O dons <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lfdlJfe�rfromobove): ❑ Owner ❑ Operator ❑ Employes <br /> Designated Operator's Phone 0: ❑ Service Technician ❑ Third-Party <br /> Itaemetiond Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opliond) t <br /> Designated Operators Name: Relation to UST Facilily(Check One) . <br /> Business Nemo(rfd{ffe tfrom above): ❑ 0w ❑ Operator ❑ Employee <br /> Designated operators Phone a: ❑ Service Yechnieina D Third-Party <br /> International Cod.Council Certification#: Expiration Dm: <br /> NOTE:THE LOCAJ,REGULATORY AGENCY MUST BE NOTTFMD OF ANY CHANCES 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 stora a cs. <br /> r-- <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE:_ /���3 -0`( OWNER'S PHONE#�.2��) 1fs�`0l0/ X3/9 <br />