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UC!141 Mrj f .LCI:Di ZUn40bn4.nZ <br /> San Joacl'in County <br /> Environmental H�alth f)epa>rtMent <br /> 304 F.Weber Ave.,Third floor Stocktoxi CA.95202 <br /> Telephone(209) 468-3 20 Fax(209) 468-3933 <br /> Owner Statements of Designated Und;rground Storage Tank(UST) Operator <br /> and Understanding of and Com Nance with UST Requirements <br /> Facility Name: ' Facility ID#- <br /> 1•acI ft Address: Reason for Submitting this F6rm(Check Ori) <br /> C�' flange of Designated Operator <br /> Facility Phone ir: 0 'Update Cczificate)rxplraflon Date <br /> Designated UST Que or(s)fo 's aailit <br /> rRIMARY <br /> ]Designated Operaror's Name; Rclstion no'UST Pacillty(Check One) <br /> .l3vs[ness Namo(jf dWersne fr&x abOVP); <br /> 0 0 owner El.Operator .0 EmploVee <br /> Designated Operator's Phone#: Sernicn I'aehttician U Third4a.rty <br /> International Code Council Certification#= <2—:f-1& Expiration Date: <br /> ALTERNATE 7 O ttonal <br /> Designated Operatzar's Natnc; .0-- ej. Refarlon m'GsT);aeiIhy(Cheek One) <br /> 13usiness Name(Ifdefferenl front above): A al. f 0 Owner C1 opemwr C7 Employee <br /> Designated Operator's Phortc#: Se vicc Techn man 0 ]bird Party <br /> Int=Cion,al Code council Cenftadon#: � � Fa pirati..Date: -�D <br /> ALTY,V-NATE 2 (tJptionaV <br /> Lledgnated Operator 5 TVame. Relation to UST FwAlty(Check One) <br /> Business NaTne(Cfd erE+td frolri abos ): _ a i7 Owner ❑ Qparatar ti Employee <br /> Designated Operator's Phone#: � � f � q. Service-Teahniclan 0 Third Party <br /> Inzarnational Code Council Certification A. r _ Expi-non Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY T BE NOMI ED OF ANY CMkNGES TU TMS <br /> INFORMATION WITEMq 30 DAYS O'F CE AANCE. <br /> 1 certify that, for the facility indicated at tlxe top;'=f this page, the individual(g)listed above will <br /> serve as Deaipg tad UST Operatax(s). The indi,:idual(s)will conduct and doctlmont montWy <br /> facility inspections and amual facility employe 'training,in accordance v th Califoroi,a.Code of <br /> Regulations,title 23,section 2715(c)--(f). <br /> Furthermore,f understand and ain in comph ce with the requirements(statins, <br /> reguxat�ons, and local ordin mees)appHcalble."O UndelrgroUxLd storage to <br /> N_AKME OF TANK OWNER(Please-Mat): e"f <br /> SIGNATURE UF"FANK OWNER: . <br /> DATE., � — ! �—� OWNER'S? HONE -�)�� <br /> f <br /> Navaniber 2004 ' <br /> 000 'd <br /> 9O1086OZi 'n1' f;V 'HNA SM SOH MOO Pid 50: 10 all/GOOZ/5i/EHd <br />