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• San Joaquin County . <br /> Environmental Health Department E I /E D <br /> 304 E. Weber Ave., Third Floor Stockton C i... tl <br /> Telephone (209) 468-3420 Fax (209) 468-3433 <br /> MAY 19 2014 <br /> Owner Statements of Designated Underground Storage Tank <br /> and Understanding of and Compliance with US` WY RAWA <br /> Facility Name: Valley Pacific Petroleum Shane and Daves Cardlock Facility ID#: <br /> Facility Address: 3550 S. Highway 99 Reason for Submitting this Form(Check One) <br /> Stockton, CA 95205 ❑ Change of Designated Operator <br /> Facility Phone#: 209-948-9412 01 Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: G. Michael Eliason Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator M Employee <br /> Designated Operator's Phone#:559 732-8381 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5250416-UC Expiration DateA/1/2015 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:,James Abbott Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator IN Employee <br /> Designated Operator's Phone#:209 601-4641 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8006067-UC Expiration Date: 5/15/2016 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii erentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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) - (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): Mike Eliason <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 5/15/2014 OWNER'S PHONE#: 559 732-8381 <br /> wr,,.,--, -1nnn <br />