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San Joaquin County <br /> -� -- -- Environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 J �� <br /> I Telephone(209)468-3420 Fax (209) 468-3433 <br /> DEC 2 1 2004 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator TH <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: FOOD MART FacilitylD#: FA0000091 <br /> Facility Address: 14000 E. HWY 88 Reason for Submitting this Form(Check One) <br /> LOCKEFORD, CA. 95237 ❑ Change of Designated Operator <br /> Facility Phone#: 209-727-5442 1;1 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Faeility <br /> PRIMARY <br /> Designated Operator's Name: DENNIS TWEEDY Relation to UST Facility(Check One) <br /> Business Name(Ifdei ferent from above): TIME OIL CO. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 425-210-7998 D Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5244489—UC Expiration Date: <br /> ALTERNATE 1 (O tiona! <br /> Designated Operator's Name: ,JIM SIMS Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferem from above): TIME OIL CO. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 206-310-7544 )(J 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(If different from 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 /> 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) applicable to undergro=snd storage tanks. <br /> NAME OF TANK OWNER(Please Print): TIME OIL CO. <br /> SIGNATURE OF TANK OWNER: <br /> DATE: DECEMBER 14, 2004 OWNER'S PHONE#: 206-285-2400 <br /> November 2004 <br />