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12/28/2004 10:38 2098582666 TWO GUYS PAGE 01 <br /> 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 /> Fa tvName: L&jijEte CrA r Fop 1yfttT' Facility ID#: -jy�o <br /> Facility Address: 114800 S. H V Y 91 F RONT196F KJ. Reason for Submitting this Form(Check One) <br /> Cf} CA QS3'L A Change of Designated Operator <br /> Facility Phone#: py 39-Al I'l C?-Update Certificate Expiration Date <br /> Designated UST Operator(s) for tbis Facility <br /> PRI hf ARX <br /> Dcsi�d Operator's Name: �yg f&0,L CA-ruA AG 1S Relation to UST Facility(Check One) <br /> Business Name(If dffferenr froth above):.r a +Fu O Owner ❑ Operator b Employee <br /> Designated Operator's Phone# at 5 -,26 ❑ Service Technician ❑ Third-Patty <br /> International Code Council Certificavon#; QFC' A n, Expiration Datc: 11-14-06 <br /> DL <br /> AL`fERNATE 1 (O riwta! <br /> Ucsignated Operator's Name: o FL �'RAW FOQk Relation to UST Facility(Check One) <br /> Business Name(Ifdiferenffrontobovo):G pj9l0A1 w ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone q.17 — 1515 1 6L Service Technician ❑ Third-Party <br /> International Godc Council Cenificatinn#:51`µ `T_VG Expiration Date: 9-11-06 <br /> ALTERNATE 2 (Optional) <br /> [ Desr ignatcd Operator's Numc: j MFERI 7F) Relation to UST Facility(Check One) <br /> i <br /> Business Name(1fd(ffwnefront above.):VMMplO I/ Pocksov Q Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 9 - rj' JL Service Technician O Third-Party <br /> International Code Council Certification#:(A EC y71 A � Expiration Date; -11-06 <br /> NOTE: TIME 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): t C <br /> SIGNATURE OF TANK OWNER: <br /> DATE: r'L AS-0—f OWNER'S PHONE <br /> November 2004 <br />