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. San Joaquin County .� <br /> Environmental Health Department <br /> 304 E. Weber Ave. Third Floor Stockton CA 95202 J� <br /> Telephone (209) 468-3420 Fax (209) 468-3433 C <br /> DEC 13 2004 <br /> Owner Statements of Designated Underground Storage Tank (U§QWprator <br /> and Understanding of and Compliance with UST Re uiren l �rlbiLjIFISERVICES I <br /> W l Facility Name: a S Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> lQ Afv-rHL. r� ❑ Change of Designated Operator <br /> Facility Phone#: — 6,64,Y ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(if differeni fivan above). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(V dii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name Qfdii ferent from 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 /> VV d N c�/ �urQ S tis 701nfN S. <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 /> cc/*q-zo OF TANK OWNER(Please Print): �/J42 v'7 4m S <br /> SIGNATURE OF TANK OWNER: l� �f` / c� <br /> DATE: /S- Jt -Oq OWNER'S PHONE#:C r A 223 <br /> November 2004 <br />