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FROM (THU)DEC 30 2004 14:11/ST. 14: 10/No. 6818885743 P 2 <br /> NOW Sid <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E.Weber Ave.,"Third Floor Stockton CA 95202 <br /> Telephone(209)46843420 Fax(209)468-3433 ' <br /> Owner Statements of Designated Undcrground Storage Tank(UST) Operator <br /> and I3liderl;ulnding of an() C'onlpliance with LJST Requirements <br /> Facility Namc Valley Perdfic Peboieom Services.llm_ _._ _ __ Facility ID 4;FA0005,5g4 _ <br /> Facility Address: Reason for Submitting this Form(CI One) <br /> 930 E.View Rd.,Lodi,GA 95240 ex, Olangc of f3 aignated Operator <br /> Faculty Phone 20g 33q_395$ ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facillty <br /> PR1htAR1' ___ <br /> Dcsig,rnted Operator's name:Mike Eilason - <br /> —Tie <br /> to OST Faeitity(C'haek one) <br /> Business Namc(/fdt#rmrrfroorabolr):Vailey Pacific Petroleum Svcs,Inc. ❑ Otvoer ❑ Oporator F.mpto)VC <br /> ._. .............__. .__—_ _,.,.. <br /> Designated Operator'sl'hnncd:(209)993-9793 O Scrvicc'1'tthnician ❑ 'f'hird-PartY_- <br /> Intcmmiongl Code Council(snificatiol(k141014087 --' EsPintton Date_--____...... _l <br /> ALTERNATE 1 f0/,tronnf <br /> Daignaterl Operator's Naiyfobed Robertson Rel.tion to UST Facility(Cheek O.,$) <br /> t3usinen Namc ohrr*(ey p9eft peyp19Urn SVCS,Inc, ❑ Owner 0 Operator X limploycc <br /> U, esignaaod Olwator's piwnc N 209 327-8995 -__ _ ❑ SeMec Technician -0 Third Party <br /> International Codc Council L.011"cut lust 4:ROK00054 Extaratim Date: — <br /> ALTERNATE 2 (OprienalJ <br /> IXsignntal ONtalor's Name: Relation to UST Facility(Chrrk One) <br /> Business Namc(IfdiWnyrlfrom abrn'r): 0 Otmer 0 Operator ❑ Employee <br /> Ocsignala:opentofs Phone d: O Service Technician 0 "Wird-Party <br /> International Code Colnlci(Ccuificutiva q: - Expiration Dole: <br /> NOTE:THE LOCAL REGULATORY A(;FN('Y MUS'C BE N(YrIFtED OF ANY CHANGES TO'rHIS <br /> INFORAIATION NYIT'JHN 30 DAYS OF THE CHANGE. <br /> I certify that,for the facility indicated at(lie top of this page,the individuals)listed above will <br /> serve as Designated UST Operaler(s). The individuaI(s)will conduct alld document monthly <br /> f teility inspections andannual 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): ITOrm Clum <br /> SIGN ALT RT:OF TANK O\YNRik:____ <br /> DATE: 12!29/2004 ____.,_..__.__--_OWNEIYS PkIOtiF.♦!: (209)948-9412 ____._ <br /> i <br /> November 2004 <br /> VPPS Lodi COMM.max <br />