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Sara Joaquin County 0 <br /> Environmental Health Department <br /> 304 E. Welber Ave.,Third Floor Stockton CA 95202 ", `j 4 -1 <br /> Telephone (209) 468-3420 Fax (209) 468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Qperator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: IskLI n c; 'Sf Facility ID#: r <br /> Facility Address: Ll 8(DD 5. tr i >r POr-t Lj u Reason for Submitting this Form(Check One) <br /> - f c — p� � ['it Change of Designated Operator <br /> Facility Phone#:skociort�p r / ❑ Update Certificate Expiration Date <br /> Designated UST operator(s) for this Facili <br /> PRIMARY <br /> Desicnated Operator's Name: Relation to UST Facility(Check.One <br /> r <br /> Business Name(!f different frons above): ❑ Owner Operator Employee <br /> Designated Operator's Phone#Qcqj)�q q �� ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: r Expiration Qate: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ operator ❑ Employee <br /> ❑ Service Technician ❑ Third-Party <br /> Designated Operator's Phone#: <br /> International Code Council Certification#: Expiration Date:- <br /> ALTERNATE 2 (Optional) _ <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <br /> Business Name(If different from above): ❑ Owncr ❑ Operator ❑ Employee <br /> Designated Operator's Phone 4: ❑ Service Technician ❑ Third-Party <br /> International 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) - (0. <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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: J — — OWNEFCS PHONE#: �� 1 O c s <br /> so <br /> November 2004 <br />