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Environmental Health Department <br /> E. Main Street 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 /> FacilityName: j44/,, --,aj2�6 <br /> Facility Address: cr� H- Facility ID#: <br /> fp� Reason for Submi 'ng this Fomt(Check One) <br /> ❑ Change of Designated operator <br /> Facility Phone#: <br /> ❑ Update Certificate Expirnfion Dale <br /> Designated UST Ooerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: pI;fl 15�eLiZ <br /> Relation to UST Facility(Check One) <br /> Business Name(/jd�erent jrom above): <br /> Designated Operator's Phone#: _ <br /> / ' T ❑ Owner ❑ Operator ❑ Employee <br /> 6y � q, / <br /> U" ❑ Service Technician IR/Third-Party <br /> International Code Council Certification#: _J]16 <br /> Expiration Date: <br /> ALTERNATE 1(O [lona! <br /> Designated Operator's �Name: Relation to UST Facility(Check One) <br /> Business Name(Ijdi�'eren[jrom above)):: <br /> ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: p ty <br /> - ❑ Service Technician [9 Third-Party <br /> International Code Council Certification#: <br /> (} Expiration Dale: r�3 i <br /> ALTERNATE 2 (Options!) <br /> Designated Operator's Name: <br /> Relation to UST Facility(Check One) <br /> Business Name(Ijdierent jrom above): <br /> Designated ❑ Owner ❑ Operator ❑ Employee <br /> gn 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 /> APR <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 atl(9 document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, or <br /> 23, section 2715(c) - (f). <br /> Furthermore, 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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: —. tr OWNER'S PHONE#: — Y �7 <br /> November 2004 <br />