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12/26/2004 19:01 209831F' TRANSPORTATION PAGE 04/07 <br /> San Joaquin County ve <br /> Environmental Health Department <br /> 304 E. Weber Ave-, Third Floor Stockton CA 95202 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> 2tj=gn7EDChwSc <br /> Name.- <br /> Facility <br /> Facility ID#: <br /> J �., ttiG Reason for Submitting this Form(Check One) <br /> ❑ Chane of Desi G S grated Operator <br /> ❑ Update Certificate Expiration Data <br /> Designated UST Operators for this Facility <br /> PRIMARY --' <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lfd&m,t from above): <br /> Designated Operator's Phone <br /> ❑ owner ❑ Operator gypmployce <br /> #; �� _ 3 / El Scrviee Technician ❑ <br /> International Code Council Certification#: Third-Parry <br /> ALTERNATE 1 O tiaaal Expiration Date: <br /> Designeratntcd Opor's Name. <br /> � CL'p Relation to USTFaciliry(CheckOrse) <br /> Business Namc(ifdifferenrfrom above); <br /> Des" ated ❑ Oxmtr 0 Operator 04mployee <br /> tgn Operator's Phone#: LT _$�O� O Service Technician <br /> International Code Council Certification# ❑ Third•Party: <br /> Expiration Daze: <br /> ALTERNATE 2 (Optwaalj <br /> Designated Operator's Name: <br /> Re]azion to UST Facility(Check puJ <br /> Business Name(ljdiff�ent from above): <br /> Designated ❑ Owner ❑ Operator Cl Employee <br /> Sn Operator's <br /> [ntemaziona(Code Council Certification#: ❑ Service Technician ❑ Third-Party <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 /> I certify that, for the facility indicated at the top of this page,the individual(s)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,in accordance with California Code of <br /> Regulations, title 23, section 2715(c) <br /> F urthermore,I 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 Print): f c c d 1 D <br /> SIGNATURE OF TANK OWNER: <br /> DATE: )d OWNER'S PHONE <br /> November 2004 <br />