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San Joaquin County RIECO " ED <br /> Environmental Health Department SEP 2 4 2010 <br /> 600 E. Main Street Stockton CA 95202 ENVIHUNMENT HEALTH <br /> Telephone (209) 468-3420 Fax (209) 468-3433 PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 6D pdtWCU�Vpj Facility ID#: <br /> Facility Address:1 or 78 A), AP&j4V¢Y I?Cf c• W oAv14-G6 Reason for Submitting this Form(Check One) <br /> AJ c-A 9(Change of Designated Operator 140 ACN fC <br /> FacilityPhone#: Z,6 + (p(,$� ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: j SS6 ^�11G�.N Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): (� A fA Lfa ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone -")O V Service Technician ie Third-Party <br /> International Code Council Certification#: f v Expiration Date: �A Zai p <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: J MG•S PAY A) Relation to UST Facility.(Check One) <br /> Business Name(If different from above): ( ❑ owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: �.t'Xj 3 p0 C9'Service Technician �Third-Party <br /> International Code Council Certification#:sZ 6 7 ,( — t/ Expiration Date: �j- <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different 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. <br /> NAME OF TANK OWNER(Please Print): <br /> a co 1ytrIy-00 <br /> SIGNATURE OF TANK <br /> 1, g- j;4+L&20g2026 co <br /> 19, <br /> DATE: �� 2D(a OWNER'SPHONE#:(�flCfl Q3r — ro�S 'I <br /> November 2004 <br />