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� s <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: uper Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 16888 McKinley Ave Lathrolp, CA ❑ Change of Designated Operator <br /> Facility Phone#: 209-858-3384 O Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: XeV=,— Relation to UST Facility(Check One) <br /> Business Name(1fdii erentfrom above) ❑ Owner )b Operator ❑ Employee <br /> Designated Operator's Phone#: 2nq_ _ jg4 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 O Nona! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(if diiferentfmm above): ❑ Owner V Operator ❑ Employee <br /> Designated Operator's Phone#: 209-858-3384 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opliona!) <br /> Designated Operator's Name: ath Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from ove): ❑ Owner jh 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 /> 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): Sp.Wrr�� Store Industries <br /> SIGNATURE OF TANK OWNER: �,.fti <br /> DATE: 12, — 9^ 0 9 OWNER'S PHONE#: (209) 858-3384 <br /> November 2004 <br />