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DecIL <br /> 30 04 11 : 03a � � P' 2 <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)4683420 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: A�S t,., ' ,. 'r <br /> Facility ID#:. <br /> Facility Address: p,.3q �` }nJ ice. Reason for Submitting this Form(Check One) <br /> ? ,0,j , �1 0l 5 3 to to W Change of Designated Operator <br /> Facility Phone#: q S�` '- :31 1 S 0 Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: (A-V a� Relation to UST Facility(Cheek One) <br /> Business Name(Ifdiffereut from aboveJ R owner o Operator D Employee <br /> Designated Operator's Phone#: D j -- ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: , <br /> ALTERNATE I (D (iortaf <br /> Designated Operator's Name: y-y)t,`Vie_ Relation to UST Facility(Check One) <br /> Business Name(1f differeru fronr above)., 20,6N � �* ❑ Owner D Operator ❑ Employee <br /> Designated Operator's Phone#: 2 p G) S 3 7 --. )3 q i, E!/Service Technician ❑ Third-Parry <br /> International Code Council Certification#: 6aLl S q y a � U G Expiration Date: I -mop la <br /> A! rikw' TE 2 (Optional) <br /> Designated Operator's Name: 'R�;6r, L ' o ,` Relation to UST Facility(Check One) <br /> Business Flame(IfdiJfereut from above): XD'A 21- 3 0 Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ii: )�p Ci 6 3 -7 _ !y 3 al a/Service Technician ❑ Third-Parry <br /> International Code Council Certification#i; Jr -2 y 3-75 S - U G Expiration Date: L -2 7 -P pp(, <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS Or, 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 Cade of <br /> Regulations,title 23, section 2715(c)- (f). <br /> Furthermore,Y understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAIVE OF TANK OIYNER(Please Print . c �'� <br /> SIGNATURE OF TANK OWNER: <br /> DATE: ), ' 3 Q - -a 'A OWNER'S PHONE#: aCA S 3_7 1 <br />