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0 San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209) 468-3420 Fax (209)468-3433 <br /> Owner Statements of Designated Underground Storage Tank (U ) Operator <br /> and Understanding of and Compliance with UST Req 'rements <br /> FacilityName: n -3 (1' e�- NO Facility I <br /> Facility Address: �S1,717 � A / sftc4.� �. Reaso for Submitting this Form(Check One) <br /> b- hange of Designated Operator <br /> FacilityPhone#: k ( 41 Update Certificate Expiration Date <br /> \1 <br /> esi mated UST O erator(sor this Facility <br /> PRIMARY <br /> Designated Operator's Name: fko v v Lr n -L ,-\z Relation to UST Facility(Check One) <br /> Business Name(If different from above). ❑ Owner ['Operator )6 Employee <br /> Designated Operator's Phone#: 6 7 Z ❑ Service Technician ❑ Third-Party <br /> International Code Councfl Certification#: Expiration Date: 3 t/10"7 <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 /> Designated Operator's 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(If different from abovel- ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certific tion#: Expiration Date: <br /> NOTE:THE LOCAL REG ATORY AGENCY MUST BE NO IED OF ANY CHANGES TO THIS <br /> INFORMATION THIN 30 DAYS OF THE CHANGE. <br /> I certify that, for th facility indicated at the top of this page,the in 'vidual(s) listed above will <br /> serve as Designate UST Operator(s). The individual(s)will conduct d document monthly <br /> facility inspectio and annual facility employee training, in accordant with California Code of <br /> Regulations,titl 23, section 2715(c) - (f). <br /> Furthermore I understand and am in compliance with the requirements statutes, <br /> regulations, nd local ordinances) applicable to underground storage tank <br /> NAME OF ANK OWNER(Please Print): �J 4, (A CIA1 I n <br /> SIGNAT OF TANK OWNER: ` C;h <br /> DATE: ( `41/y b OWNER'S PHONE#: 2- 3 Y y� Sd -� <br /> November 2004 <br />