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San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street 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:su C S Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> �1 C E > P&Change of Designated Operator <br /> Facility Phone#: d - ❑ Update Certificate Expiration Date <br /> Designated UST Ooerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check Ow) <br /> Business Name(If dl ferentfrom abovei.0 ❑ Owner 9 Operator ❑ Employee <br /> Designated Operators Phone#: 20 - O ❑ ServiceTechnician ❑ Third-Party <br /> International Code Cotmcil Certification#:47/0,F206 Expiration Date: S` Li „ <br /> ALTERNATE t0)fionaQ <br /> Designated Operator's Name: > Relation to UST Facility(Check One) <br /> Business Name(If differentfmm above): S• t& ycL07; r ❑ Owner ❑ Operator )?' Employee <br /> Designated Operalor's Phone#: - 3 ElService Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE S (Optionay <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii fermt from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 9; ❑ 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 WrrHIN 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): <br /> SIGNATURE OF TANK OWNER: �4A.G/' + I @ S (yianc�e� <br /> DATE:_: ,t(\P , SOI 1 OWNER'S PHONE#:_ - RS-a 3322 <br /> November 2004 <br />