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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: %" 'fQ 2 LAC Facility ID#: <br /> Facility Address: j/�'JB j IW' 6,IMV--" W4/ r Reason for Submitting this Form(Check One) <br /> ?7aCexaf 64' In 14'&ange of Designated Operator <br /> Facility Phone#: p - /- ZZ 2Z ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 40—ea .orw SH,010s-: R�ela/tio'n to UST Facility(Check Om) <br /> Business Name(If di_Qerem from above): d'Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 3&-///0 ' 0// ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Dn(p - C. Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii erent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opdonao <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifiti erenrfrom 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. <br /> NAME OF TANK OWNER(Please Print): y12j1Xj P2 cB1(�Uf <br /> SIGNATURE OF TANK OWNER: Crj o ` <br /> DATE: "7/�� OWNER'S PHONE#: <br /> November 2004 <br />