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ti _ �a2o(o <br /> San 7oaquin County REc <br /> Environmental Health Department 111 �� 3 <br /> 600 R.Main Street Stockton CA 95202 <br /> Telephone(209)469-3420 Fax(209)468-3433 SEP 17 2013 <br /> Owner Statements of D esignated Underground Storage Tank(UST)OpMMENTAL <br /> and Understanding of and Compliance with UST Requirements HEA�TO 4FiTMENT <br /> FacOiryA'ame: Facatty tD01: <br /> ' Fsml{ty Addras:tp'� �-ror�keuu� Rmsoa forbwbossaiag thl:Form(Check Oae) <br /> Cfl �('hange ofDestgwted Opmtm <br /> Fndatq Yhme,".:Z - ❑ Update Certificate 2xpimflonDa2 <br /> Designated UST Operator(s)for this Facility <br /> PRE"Ry <br /> Dceg,ated Opus;esNsma: - Relation to UST Facility(Check One) <br /> Business Name(Ifdffaradfrom above): ❑ Omer o Operator ❑ Employee <br /> Designated Opecntoes Phone's: 6�1 O service Teowcim WrT�hird-Party <br /> Inlecnationat Code Council Certification.$. S �'l ExPns +batc: -1 T ALTERNATEI don. <br /> Designated OpawoesNzaw. Relation to USTFacitity(Check One) <br /> Basln.ssNmu(7fdffwzm'from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's nonei{: ❑ Sesviw Treis,ticiea ❑ Third.Party . <br /> Intmtationel Coda Comcfi CmUcadonh: Expiration Date; <br /> ALTERNATES (OpdoulJ <br /> Deigaamd OpratoesName: RrdaOon to USTFaality(Check One) <br /> BaalneuName({fdffera.from above): ❑ Owner ❑ Opmfor O Employee <br /> Dalgnated Opmtar'aPhene R: ❑ Service Tochoician ❑ Third-Party <br /> International Code council Certificadau ik Expiration Date: <br /> NOTE:THELOCAL REGULATORY AGENCYMUST BE NOTnIMD OB ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify dlA for the facility indicated at the top of this page,the individual(s)listed above will <br /> serve as Designated UST Operator(s). The individuals)will conduat and document monthly <br /> facility inspections and annual facility employee training,in accordancewith California Code of <br /> Regulations,tide 23,section 2715(c)-(fl. <br /> Farfharmore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks_ <br /> NAME OF TANK OWtMR(Please Print): �/+ I A/ S r <br /> SIGNAITYRL+OF TANTO OWNER= <br /> DATE: O q 1 a2 a(u, OvaMIS PHONE M .101- <br /> November 2004 <br />