Laserfiche WebLink
• DEC. 22 2004 11 : 08AM AG SPANas JET CTR <br /> NO. 236 P. 2 <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)468-3133 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Fa6lity Nate: ^C. <br /> Facility Address: iieob 4 ,- Orj 2 Facility 1r)#: <br /> I- � Reason for Submitling this Form(Check One) <br /> Facility Phone#: � — <br /> )r Change of Designated Operator <br /> ❑ Update Certificate Expiration Date <br /> esi Hated 1 ST Overat s for tlxis Facilit <br /> PRIMARY <br /> Designated Operator's Name: ' <br /> Relation to UST Facility(CheckOne) <br /> Business Namc(f dlferena fi-om above); <br /> a Owner OperatorEmployee <br /> Designated operator's Phor1C#; 2—� <br /> 11.J service Technician ❑ Third-PAY <br /> International Code Council Ccrtiflcation# <br /> Expiration Date: <br /> ALTERNATE 1 O lienal <br /> Designated Operator's Namc; <br /> Business Nam(Ifdierent�rom above): Relation to UST facility(Check One) <br /> b Owner ❑ operator Q Employee <br /> Dcsig:eated Operator's Phone#: ` <br /> International Code Council Certif:cation�#; ❑ Service Technician d Third-Party <br /> ALTER,NATE 2 (pprppetalj Expiration Datc,- <br /> Dcsignated Operator's Namc: <br /> _ Relation to UST Facility(Check one <br /> Businass Marne(If r!(�erc�ttJro,n above). —�"" ) <br /> Q Owner © Operator a Employee <br /> Designated Operator's Phone#: <br /> 1•nterngtional Code Council Cerlificstlian#; <br /> ❑ Service Technician ❑ Tptlrd_party <br /> ----- Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES To THIS <br /> INFORMATI[ON WITHIN 30 DAYS O-'THE CHANGE. <br /> Fthat, for the facility indicated at the top of this page, the individual(s)listed above will <br /> Designated FUST Operator(s). The individuai(s)will conduct and document monthly <br /> nspections and annual facility employee training, in accordazzce with California Code of <br /> Regulations, title 23, section 2715(c) - (t). <br /> Furthermore, I understand and am in compliancewith the requirements (statut <br /> regulations,and local ordinances) applicable to uDderground storage tanks. es, <br /> NAME OF TANK OWNER(Ptettserint): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 1 — OWNER'S PJRONF.#: 10 a � �J� <br /> November 2004 <br />