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jxN-06-2005-THU 12;37 PM P. 005 <br /> Doc 22 04 03: S5p Franzen Hill SS9B881467 p. 4 <br /> Sala Joaquin County <br /> Environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(2 09)468_3420 Fax(249)468-3433 <br /> Owner Statemt—nits of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityNnmc: RSM-Stockton FacilityMM N-5013 <br /> FacilityAddress: 11109 Airport Way Keasonfor Submitting this Form(Cbeckone) <br /> Stockton, CA X Change QfDcsignatedOperator <br /> FacilityPhoneH Q9) 942-2$40 ❑ Update CcrtifioaroExpirationDate <br /> Desi hated UST O erator s for this Facility <br /> PIZIMrARY <br /> Designated Operator's Name: Franzen-Hill RelatioratoUST Facility(ChQOne) <br /> Business Name(lfd�ererrlfram abov+e): p Owacr ❑ Operator Dmignared Operator's Phone ii: 554-688-2977 Service lechaieian X International Code Council Cclification#: 5245124—UC ExpitationDatc: 11-19— <br /> ALTI?RNATL• 1 D rianal <br /> Desipated operator's Name: Relation to UST Facility(Check One <br /> Business Name({jderenrfram above). ❑ owner ❑ Operator ❑ Employee <br /> DesiRTwcd Operator's Phone d: O Service Technician- A Third-parry <br /> lntcrnational Code Council Certification#: Expiration Date: <br /> ALTtrRIA,TE 2 {Optional} <br /> Designated Operator's Name: Aelation to UST Facility(Check One) <br /> Business Name(ffdi(ferentfrom above), d owner ❑ operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Techniciatt ❑ Thud-patty <br /> Iatemational Cade Coumcil Cenifccatiou iv, FExpitation Data: <br /> NOTA,:TRE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO T1[IIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> Frtify that, for the facility indicated at the top of this page, the individual(s) listed above will <br /> e as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> lity inspections and annual faciliti employee training,in accordance with California Code of <br /> ulations,title 23, section 2715(c)-(f). <br /> Furthermore,I understand and am ie compliance with tate requirements(statutes, <br /> regulations,and local ordinances)applicable to underground story et les, <br /> NAME OF TANK OWNER(Please Print): <br /> } SIGNATURE OF TANK OWNER: <br /> iDATE: 3—� OWNER'S PHONEr � /C) <br />