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-Nov 29 10 01:22p Reliable PetroleumA 209-845-8953 p.3 <br /> • • <br /> San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax (209) 468-3433 <br /> Owner tatements of Designated Underground Storage Tank (UST) Operator <br /> d Understanding of and Compliance with UST Requirements <br /> FaciiityName: V('0v%. Facility ID#: <br /> Facility Address: 5'08,,tom] . _ V30LIA - Reason for Submitting this Form(Check One) <br /> 1•'OYL lJ`1- • UVJ-l5 24(O B( Change of Designated Operator <br /> Facility Phone#: b S - 314 'L40 ❑ Update Certificate Expiration Date <br /> Desilsnated UST Ooerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: i- e' � Relation to UST Facility(Check.One) <br /> Business Name( f dii erenr from above h 4ClJY-�- Qa/i Owner ❑ Operator ❑ Employee <br /> Designated Ope is Phone q _ to Service Technician ❑ Third-Party <br /> Tntcrnational Cod Council Certification#: 5 _SLl1 p Expiration Date: I z 023 1 <br /> ALTERNATE I donei <br /> Designated Opera or's Name: Relation to UST Facility(Check One) <br /> Business Name(I dferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Opere is Phone#: ❑ Service'rechnician ❑ Third-Parry <br /> International Cod Council Certification#: Expirafion Date: <br /> ALTERNATE 2 Opfional) <br /> Designated Oper is Name: Relation to UST Facility(Check One) <br /> Business Name(/ dierentfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's r'sPhone 9: C Service Technician � Third-Party <br /> fntcmational Code Council Certification#: Expiration Datc: <br /> NOTE:THE L CAL REGULATORY AGENCY-MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> MFOR NIATION WITHIN 30 DAPS OF THE CHANGE. <br /> I certify that, I or 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 inspeci ions and annual facility employee training,in accordance with California Code of <br /> Regulations, title 23,section 2715(c) - (f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations, a lid local ordinances) applicable to underground storage tanks. <br /> NAME OF TAY K OWNER(Please Print): U 1Z A)K3a <br /> SIGNATURE O T TANK OWNER: <br /> DATE: ( I 3 ry OWNER'S PHONE#: 42q4 _ e7 2 -J29,5' <br /> onnn <br />