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N.. <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 68221 <br />Facility ID #: <br />Facility Address: 2132 MARIPOSA ROAD <br />STOCKTON, CA 95204-3937 <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-465-4756 <br />Designated UST Operator(s) for this Facility <br />rnunnnr <br />Designated Operator's Name: Jason C Kirby <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (If different j-om above): Delta Environmental Consultants, Inc <br />Designated Operator's Phone #: 530 320.6102 <br />International Code Council Certification #: 5270158 -UC <br />Expiration Date: 10/01/2007 <br />r TCONATE 1 <br />Designated Operator's Name: Randall M Kirby <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (Ifniferentfirm above): Delta Environmental Consultants, Inc <br />Designated Operator's Phone #: 916-870-5932 <br />International Code Council Certification #: 5250566 -UC <br />Expiration Date: 10/7/2008 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: refer to backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician g Third -Party <br />Business Name (If different from above): Delta Environmental Consultants, Inc <br />Designated Operators Phone #: refer to backup document <br />International Code Council Certification #: refer to backup document <br />Expiration Date: refer to backup document <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated <br />UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility <br />employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please <br />SIGNATURE OF TANK OWNER: imc7W Zrttj� a — s G C(� <br />Date: 7 - Owner's Phone#: J --y-1- <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2008. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: httn://w�,w.waterboards.ca.eov/ust/contacts( ___ _ <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />June 2007 <br />