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• RECEIV . <br /> San Joaquin County �® <br /> Environmental Health Department MAY 0 8 1014 <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> RONMEN <br /> Telephone(209)468-3420 Fax(209)468-3433 PERMIT SZAL HFA <br /> EERVICLrH <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Faz 0 1" Facility ID#: <br /> Facility Address: (� Reason for submitting this Form(Check One) <br /> -I Li q C X Change of Designated Operator <br /> FacilityPhone#: 'aQ — y 6 — ❑ Update Certificate Expiration Date <br /> Desienated UST Ooerator(s)for this Facility <br /> PRIMARY 't< <br /> Designated Operator's Name: A+hRelation to UST Facility(Check One) <br /> Business Name(Ifdiffmntfrom above): ❑ Owner ❑ Operator ❑ Employce <br /> Designated Operator's Phone#: _ -3 6 ' ❑ Service Technician A Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 bona[ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdi.Q'emnt from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operames Phone#.' ❑ service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ 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 /> %NuWOV-e t O P��Ivrm ins Veer C��re yy � �izPoc�l o ►� P�v C�rlctn <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)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicableto <br /> _underground storage tanks. ' <br /> NAME OF TANK OWNER(Please Print): j In Ll I✓l41 �2� ttJ,� t''\I <br /> SIGNATURE OF TANK OWNER: <br /> DATE: Jam" 'I OWNEWS PHONE#: aoq- LA 65- P,4-19 <br /> November 2004 <br />