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BB/2512006 14:08 2093697PI3 WINE COUNTRY STATION <br />PAGE 61 <br />0 0 <br />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 (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name; ( fine <br />COUN'rAtj <br />Facility Address: s Lt" d Facility !D #; <br />1 1 16. k 67?_LCMA4% 1 L AN Cs` Reason for Submitting this Farm (Check One) <br />0 Change Of Designated Operator <br />Q Update C=ertificate Expiration Date <br />Designated U•ST Onerator(sl fur this Facility <br />Designated Operator's Name: j () N " <br />Business Name (Ifdrffereru from above); <br />Designated Operator's Phone h: 4)6— <br />International Code Canned Certification #: <br />ALTERNATE I (Optional <br />Designated Operator's Name: <br />Business Name Vfdifferenr fron, above): <br />Designated Operator's Phone #: <br />International Code Council Certification f!; <br />ALTERNATE 2 (Ortlnna!) <br />Designated Operator's Name: <br />Business Name Q(dfj)'erent from above): <br />S'T &Rid&S I Relation to UST Facility (Check One) <br />fio ) .0 Owner ❑ Operator ❑ Employee <br />l— 23 to I D( Service Technician K Third -party <br />2_412-q2 „ UC, Expiration Date; 06 <br />Relation to UST Facility (Cheek One) <br />0 Owner ❑ Operator Cl Employee <br />❑ Service Technician ❑ Third -Party <br />Expiration hate: <br />Relation to UST Facility (Check One) <br />(3O%vncr ❑ Operator 0 Employee <br />Designated Operator's Phone #; ❑ Service Technician ❑Third -Party <br />International Code Council Certification: <br />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 />1 certify that, for the facility indicated at the top of this page, the individuals) 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, inaccordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, X understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Pri p: ( yP b/A;T �c <br />SIGNATURE OF TANK OWNER: � <br />DATE: 2 Li L+ OWNER'S PHONE #r 6 1 b <br />Novein her 2004 <br />