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FIROM MANTECA LIQUOR AND FOOD FAX NO. : 209 239 4550 an. 01 2005 12:58PM 131 <br /> f�4-�- San Joaquin ('ounly <br /> Ro/� U I!:Itvironmcutal health Department <br /> 304 Is. Weber Ave.,Third Floor Stockton CA 95202 <br /> Cha @ Telephone (209)408-3420 Fax (209)468-3433 <br /> 0Wt101' Statcn'tents of Dcsignate(j ihlderground Storage Tank (UST) Operator <br /> and (huicrsl.anding of au(1 (:ontpliancc with (JS'I'Recluircmcnts <br /> Facility Nan c: / _— A 'roc Facilit ]DH: -- <br /> ' Y <br /> FflCilityAddress: Reason for Submitting this Form Check Ole) <br /> 9:zo•-tr_ycS.C/rli:� RYE g <br /> /�7A,crT�G9- lp 7533 ❑ Change of Designated Operator <br /> Facility Phone H: '203- 700_x„ 0 Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY _ <br /> Designated Operator's Namc ���,Q��-E r $`f Relation to UST Facility(Check Oac) _ <br /> nosiness Nam (!j deJ)et enljma above):y,57sj ,��a« v f ❑ Owner ❑ Operator b Employee <br /> Designated Oparwtor's Phone H: rye y- Z 3C4 Ss-0 ❑ Service Technician ird-Party <br /> Intemattonal Code Council Certification it: _ Expiration Date: <br /> ALTERNATE t IO,liara!_ <br /> Designated Operator's Nanre; Relation to UST Facility(Check One) <br /> Business Namc lfdtt fema jran above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Oporwor's phone 0: ... - ❑ Scrvice Techniclan ❑ Third-Parry <br /> International Code Council Ccrtirication fi; 8xpiration Date: <br /> ALTERNATE 2 (Oprional) -- --' ` <br /> Designated Operator's Name; Relation to UST Facility(Check Ona) <br /> Business Name(Ififi femilfrom ahrrc•)__._ O Owncr ❑ Operator ❑ Employee <br /> Designated Opernlor's 1'honc d: ❑ Service Technician ❑ 'third-Party <br /> International Code Council Certification A_ Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BF.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 individuals)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 10M) ordinances) applicable to underground storage tacks. <br /> NAME OF TANK OWNER(PleasePrint):�/-I'� '1y 5:-,A/&J-/ <br /> WR 4A? : <br /> l�(/ A7�H1 <br /> SIGNATURE OF TANK OWNER: X .a S1 —g, ,' <br /> RATE:= - - OWNER'S PHONE H: 226 Z00 <br /> November 2004 <br />