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Dec 17 04 02:56p <br />DEC 2 3 2004 <br />ENVIROP!L"."��" <br />PF <br />Rffnrda-Test (20^1 794-0112 p.2 <br />.y <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 />Facility Name: eQ , 4L C <br />Facility ID #: <br />Facility Address: ay3/ RD, <br />s W�. <br />Reason for Submitting this Form (Check One) <br />L' Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: !i/ - <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designatod Operator's Name: L 10 N i mm o <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />p( Service Technician ❑ Third -Party <br />Business Name T'&ffemnifrom above): A Ve Pd4-T!S'1' <br />Designated Operator's Phone #: (20 ti) q 9N - 0 102 <br />International Code Council Certification #: N Y X0 $00cl <br />Expiration Date: 12 10 to <br />ALTERNATE I (Oalloncn <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Cl Third -Party <br />Business Name (Ifdii femrafrom above).• <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALI <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (IfdIerenrfrom above): <br />Designated Operator's Phone #. <br />Intematioaal Code Council Certification #: <br />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): .13 7 rG , L- 4! /� / <br />SIGNATURE OF TANK OWNER: ��� �G / 1.�. G'k Reg /. <br />DATEJ-'22-0 � OWNER'S PHONE #: Q6 y - 9 yI - f3% / <br />November 2004 <br />