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San Joaquin County <br />iF ' Environmental Health Department <br />V 600 E. Main Street Stockton CA 95202 <br />APR s 2010 elephone (209) 468-3420 Fax (20 9) 468-3433 <br />SANjip.Wg%> §tatements of Designated Underground Storage Tank (UST) Operator <br />IR�ger nderstanding of and Compliance with UST Requirements <br />M <br />Facility Name: % %fLti <br />Facility ID #: <br />Facility Address: <br />D <br />Reason for Submitting this Form (Check One) <br />ge of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: p 3 CIO O <br />Designated UST Ooerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: t7,�� Relation to UST Facility (Check One) <br />Business Name (Ifdii ferentyom above): Z3,_'2, , M ,tJ ❑ Owner ❑ Operator ❑Employee <br />Designated Operator's Phone #: ❑ Service Technician U.-Kird-Party <br />International Code Council Certification #: Expiration Date: <br />ALTERNATE 1 O Clonal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator Cl Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdii ferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdii ferentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 />Cr!_NATURF. (1F TANK nwNF.R. <br />DATE: 6 E 4 C OWNER'S PHONE #: <br />November 2004 <br />