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/�- pV - �,(��7 <br />7— el- 4e:2r—A r��e- <br />R r <br />Owner ,t�tterpents of Designated Underground Stogy ark (UST) Operator <br />iJ �'v "_ '.: i '. _ J <br />and Understanding of and Compliance witt T <br />cnnnRn►�►ivi} J Hu i r; tpFi I: 55 <br />PEP MIT/'&E7 L:, <br />FacilityName: Valley AM & PM <br />Facilit F J i ai L <br />Facility Address: <br />Reason Submitting't rrri�(e elk one) <br />16 E. Harding Way <br />❑Change o s or <br />Stockton, Calif. 95204 <br />/ <br />El Update Certific �at+efl--Bate <br />r <br />Facilit Phone #- 209-466-9516 <br />Designated UST Operator(s) for this Facility <br />JELRU I <br />Designated Operator's name: Dan Mcllrath Relation to UST Facility (check one) <br />Business Name: Valley Underground Tank Monitoring ❑Owner ❑Operator ❑Employee <br />Designated Operator's Phone #: 209 476-1805 ❑ Service Technician )KThird-part <br />International Code Council Certification #:XX4141012575 Ex iration Date: 11/13/2006 <br />Hnernate 'I <br />Desi nated Operator's name: <br />Relation to UST Facility (check one) <br />❑ owner ❑Operator ❑ Employee <br />ElService Technician ElThird- art <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification jEx i -ration Date: <br />MUK7-1911-4 *9 1 F4 <br />Designated Operator's name: <br />Relation to UST Facility (check one) <br />❑owner ❑Operator ❑Employee <br />❑ Service Technician ❑ Third -party <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification IlExpiration Date: <br />-• • • •� ---.�� •���...�., ¢ �,¢., AVLI\V I MUO I oe NU I IrltLl ur ANY UMANUtb Tei <br />THIS 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 serve as <br />Designatd UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br />and annual facility employee training, in accordance with California Code of Regulations, <br />title 23, section 2715 (C) - (F). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br />and local ordinances) applicable to un erground storage tanks. <br />Name of Tank Owner / <br />or Owner's Agent (Please Print):_ �f� <br />Signature of Tank <br />Owner or Owner's Agent-. <br />Date: IJ If %�js <br />�� f�' <br />�� <br />Owner'ss Phone #: <br />