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UG/lYI zoo 1CI:Oy .:UJMOOJYJJ Cf'1L rHVC UL <br /> San Joaq:Iin County <br /> Environmental B alth Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3, 20 Fax (209)468-3433 <br /> Owner Statements ofDesignated Und'rground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> .. Facility Nitre: Facility ID:k <br /> acility Address: Rcuon for 5ubtnfttiti sForm(Ch eek Ons) <br /> Ohange oSPos ted Operator <br /> Fee, Phone* 00 ❑ Update Cwpiflcate Expiration Date <br /> Desi nated TUT O erAtor s for th71attum <br /> r 't <br /> PRIMARY <br /> Dcsignared Operaro Natnc: to UST Facility One) . <br /> Business Name(Ifdi e from above): ❑ Owner ❑.Operator <br /> Designatatopmtoes Ph c#: 20 — O/% ServlccT 97 Third Puty . <br /> Intecnatioual 004 Council fication He $ Expiration ate= f Z— L _ei e-- <br /> ALTERNATE 1(Optional) <br /> Designated Opastor•s Name; t4e A4 V. Relation m USTP qa) <br /> Btuiness Namc(jfddrrau from abov O Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone�: �U .{. —O / Servico Technician ❑ Thftd-Patty, <br /> International Code Council Certification 0. 2 y G Expiration Date: 2, 3 •—O <br /> ALTIMN ATE 2 (Optiono <br /> Designated Operator's Name: `b7 Relation to UST Facility(Cheat One) <br /> .Sueioess Nun(lfdifferemfrom above)-f]" ❑ Owner p Operator ❑ Employee <br /> Designatod Operator's Phone Rt L �' Service Technician ❑ Third-Parry <br /> International Code Council Cert'Uirarionfi: lixpirarion Date: �2 _ <br /> NOTE:THE LOCAL REGULATORY GENCY T BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION wrTE 14 3 AYS OF GE. <br /> I certify that, for the facility dicated at the top' f this p e,the iadividual(s)listed above will <br /> serve as Desigazted UST mator(s). The indh idual(s) conduct and document monthly <br /> facility inspections and nal facility employeetraining,in cotdance with California Code of <br /> Regulations,title 23,s '=2715(q)-(t): <br /> Furthermore,I and stand and am in compi lee with the req rements(statutes, <br /> regulations,and to ordinances)applicable underground sto age tanks. <br /> NAME OF TANTS ERZ(Please Print): J <br /> SIGNATURE O TANE:OWNER' <br /> DAT& OV-1MM'St' HO NE <br /> Novamber2004 <br /> �00 'd 8010HHHi 'ON %Vd 'HM SS31 H03 0003 Wd 5010 IlHIAOOZ/91/93d <br />