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• 0 <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor 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: " Facility ID 4: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> G yk rhange of Designated Operator <br /> Facility Phone# (_ / Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: t ea Relation to UST Facility(Check One) <br /> Business Name(ljdiJjerent from above): �� U c ^ h ,/ ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: c 7,,3 = ❑ Service Technician rrhird-Party <br /> International Code Council Certification#: L'2 S1\ (f L Expiration Date: —7 • 'Z <br /> ALTERNATE 1 (Option( <br /> Desi nrued Name: Relation to UST Facility(Check One) <br /> Business Name(Ijdijferent from above). wner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ ServiceTec ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Desna ratoes Name: Relation to UST Facility(Check One) <br /> Business Name(ljdijferent from above ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: a Technician [I 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 undergroundstoragetanks. <br /> �. NAME OF TANK OWNER(Please Print): a-y-Qy'^ <br /> SIGNATUREOFTANK OWNER: C� <br /> DATE: OWNER'S> OWNER'S PHONE#: C-2 \ \ v <br /> November 2004 <br />