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San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave., 3r floor <br /> Stockton, CA 95202 7006 JUN 19 AM 9. 54 <br /> •"U ITY <br /> Owner Statements of Designated Underground Storag6TMO;}- 'erator <br /> And Understanding of and Compliance with UST 44tliP&&8 'ENT <br /> Facility Name: Circle K Store#27051205 Facility ID#: <br /> Facility Address: 16470 Cambridge St Reason for Submitting this Form(Check One) <br /> Lathrop,CA 95330 _ Q Change of Designated Operator <br /> Facility Phone#: (209)858-4116 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name Leslie Palmer Relation to UST Facility(Check One) <br /> Business Name(Ifdi/jerent from above).Same as Above ❑ Owner ❑ Operator El Employee <br /> Designated Operator's Phone#: 209-495-2208 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5252062-UC Expiration Date: 5/2/2007 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: See Attached List Relation to UST Facility(Check One) <br /> Business Name(If 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(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ service Technician ❑ Third-Party <br /> Intemational 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 /> NAME OF TANK OWNER <br /> OR OWNER'S AGENT(Please Print): Lorraine Soffe, Environmental Compliance Specialist. <br /> SIGNATURE OF TANK ^c�i ` ` <br /> OWNER OR OWNER'S AGENT: C��r( V t�\ Wo J <br /> September 2004 <br />