Laserfiche WebLink
San Joaquin County • <br /> Environmental Health Department DEC 3 0 2004 <br /> 304 E. Weber Ave., Third Floor Stockton CA 95202 <br /> Telephone (209) 468-3420 Fax(209)468-3433 Lf�Vll-�O'dwi O HEALTH <br /> P NiII LRVI ES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Ltoe ,1, fp0 IhBi2T Facility ID#: -34o <br /> Facility Address: 14900 S, 14y/y 97 F RouT196 f R3, Reason for Submitting this Form(Check One) <br /> CF} CA 45334 X Change of Designated Operator <br /> Facility Phone#: aoq X31-a-111 <br /> g'Update Certificate Expiration Date <br /> Desil4nated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: QfcloiL CaYrp t: Relation to UST Facility(Check One) <br /> Business Name(/jdfIferent from above):"1- u on *r. ❑ Owner ❑ Operator B Employee <br /> Designated Operator's Phone# 09 5 —ae 6 4 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: ET QHC tD VY HIV Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: 7TOrzL Q&4W F 1 Relation to UST Facility(Check One) <br /> Business Name(Ijderentjromabove)rC Ivjp10A/ Pp-ftIS10A-j ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: )1 — 165 1 §C Service Technician ❑ Third-Party <br /> International Code Council Certification#:S'3*U -VC, Expiration Date: O .I1-Ob - <br /> ALTERNATE 2 (Optional) /� . . <br /> Designated Operator's Name: j F F 1. STAT FS Relation to UST Facility(Check One) <br /> Business Name(/jdierenljrontabove:C M910/UREC1.5130 ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 9 _ 5S jk Service Technician ❑ Third-Party <br /> International Code Council Certification#:O'T YFT n L Expiration Date: _11 <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): 1L <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE �Lp �jS�o <br /> November 2004 <br />