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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements 200, SSP 19 <br />A+310: 24 <br />Facility Name: Valley AM & PM <br />J I4 i'':� .. (� .�i l� u t d'•J <br />Facility ID#:FA0003610 E <br />Facility Address: <br />Reason for Submitting this Form A406 p, <br />16 E. Harding Way <br />El Change of Designated Operator <br />Stockton, Calif. 95204 <br />KP Update Certificate Expiration Date <br />Facility Phone #:(209) 466-9516 <br />Designated UST Operator(s) for this Facility <br />r I]I INa1 <br />Designated Operator's name: Dan Mchrath <br />Relation to UST Facility (check one) <br />❑ Owner []Operator []Employee <br />❑ Service Technician IgThird-part <br />Business Name: Valley Underground Tank Monitoring <br />Designated Operator's Phone #: (209) 476-1805 <br />International Code Council Certification #:XX4141012575 lExpiration Date: 11/13/2006 <br />P%ILVIIIQL6 � <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 #: I Expiration Date: <br />.CJway <br />ITAL <br />'TRENT <br />Designated Operator's name: <br />Relation to UST Facility (check one) <br />❑ Owner ❑Operator ❑ Employee <br />❑ Service Technician ❑ Third-part <br />Business Name: <br />Designated Operator's Phone #: <br />International Code Council Certification #: Expiration Date: <br />i .+ o w ►t /HCl+ T!1 <br />Note: THL LUGAL KLUULA i UK AUr-M, I mU0 i oV- iw I n IL-� wl ­ <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 underground storage tanks. <br />Name of Tank Owner <br />or Owner's Agent (Please Print): Fawad Mohammad Ebrahimi <br />Signature of Tank <br />Owner or Owner's Agent: <br />Date: 1/13/2005 Owner's Phone #: ( 209) 466-9516 <br />