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FROM (THU)DEC 30 2004 1 It/ST. 14: 10/No. 6816865743 P 4 <br /> I <br /> I <br /> San.Joaquin County <br /> Environmental Hcstith Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Pas(209) 468-3433 <br /> Owner Statements of Designated Underground Storage 'rank (UST) Operator <br /> and C. oderstanding of azul Compliance with I ICT Requirr:ments <br /> ...._......................... . .. .. 1.111 .__............... ly Jri 0:...._...._....-----......— <br /> Facility Name_Rid Service Center FaciliFA0010452 <br /> Facility Address: <br /> —.— <br /> Reason for Submitting this Farm(Cherk One) <br /> 3550 S.HWY 98,Stxkton,CA 95215 A Change of Designated operator <br /> facility Phone::: — __— ❑ Update Cenificate Expiration Date <br /> Designated UST ODerator(s)for this Facility <br /> PItJPIARY <br /> -Ji._D—__t..s._l.g._n.—..r._I_c_d.Q....p...C..r..fl...t.n..f—S Nlnlc—'-vk-6 E.—lia_)s..O...o.....(..n_. <br /> sncsstinmcunbo,w)Vall— <br /> ..�.........a...��ic—Pe_t_r_0_-18.u._.m.._._.S.�v.r.s _❑R_c1_lOaS11n1w—wona...iec.tr _TU.tt❑ nFOl.cki.ai.rin..i. <br /> ntyoreya , Ino. <br /> Designated Opern(or" hon h:(209)993.8793 ❑ <br /> Inlclnuional Cos Cc _ (❑Che�'IcI(tk,i1GOrd1mn-11P.pt..lal <br /> _urty.y_c <br /> e_ <br /> _ <br /> 141014087 Expiration Date. <br /> AL'I'IiRNA'f}: <br /> Uailtnalttl tJpera!or's Nanlgtobert Robertson Rrlpt inn In i ISl'Fnrtifiry(ClrceAQnu) <br /> Ousincsx Name(IjJry'/f•rcm fiarrr n!?orI��IIBy Pacil(C Petroleum SVCti,Inc. ❑ 0lvncr ❑ Operator Employee <br /> ........_.----_.........._._..., <br /> Dcaignalcd Oycnuor's Phnna Yl•209 327$995 ❑ Service Technician ❑ Thiid-Par{Y.. <br /> ---...._ _. ..,_..._. ._. .___.__.-............,.... <br /> __..__.........._.._..__..—_ ._.........._ _ <br /> 0005 <br /> Intern ational Calc Council C:erufiwiion/: QK�ryl 6spirohon lJate: <br /> __ _ ._ <br /> ALTERNATE ---.-- <br /> 2 f0priunol) <br /> fl'3 <br /> signllO Opet alor's Name; Relation to UST racility(C'htrk One) <br /> __.._._._...—....—...._............._..._-_._. <br /> ❑ Owacr ❑ Operator 0 Employeesi,unatal Upcnnar'a Phooc n: ❑ ServiceTtthnician ❑ third-Party <br /> .. ._'._nernational Code Council certilicatiun 11: <br /> Expiration Date: _ I <br /> ........—._._......-111__1_.__. — __11_1___1..._ ....................� <br /> NOTE:THE I,OCAI,REGL'LA'rORY Af;F.NCY NIUS'r IIL•'N6-TIFUM OF ANY CHANGES TO'1'J113 <br /> INFORdIA'rFON vYI7'JIIrY 30 DAYS OF 7'Hk.CFIANGF,. <br /> 1...111. .... <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 tDOnthly <br /> facility inspections and annual facility ontployee training, in accordance with Cali.fonlia Code of <br /> Regulations, title 23, section 2715(c)-(I). <br /> Furthermore, F understand and ant in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print):Nonn Cru ---.---•-,r <br /> ._ <br /> S:GN.A'I't:n;5 or"rrrat:rnvNl•:u:...__._.......__.. .-._��� _. <br /> DAJ'E:1jj29l2004 OWNER1SPIIONE4: 209 948-9412 <br /> November 2004 <br /> Rapid Service Center.max <br />