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San Joaquin County Nei <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 kk -MAI <br /> Telephone (209) 468-3420 Fax (209) 468-3433 f/ 1220 <br /> 05 <br /> asSOwner ntatementofDesinnegroundSragTank UST) OperCF � <br /> stg andCp with S <br /> Facility Name: O12.05- Facility lD#: 00 S <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> r-i&qe X- r Change of Designated Operator <br /> Facility Phone#: V=oq !l// ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check Otte) <br /> business Name Qfdi fermi ft-oui above): ❑ Owner ❑ Operator �V Employee <br /> Dzsignated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: See, A'1' �- Relation to UST Facility(Check Otte) <br /> Business Name(If dii ferent from abore): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: - <br /> ALTERNATE 2 (Optiwml) <br /> Designated Operator's Name: �. A. Relation to USTFacility(Check Otte) <br /> Business Name(lf(lifferent from above): ❑ Owner ❑ 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.&""r (`�� <br /> NAME OF TANK OWNER(Please Print): ` �µ ( <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE MOV—) Z70—S-1 S 3 <br /> November 2004 <br />