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DEC 2 7 2004 <br /> LTH <br /> Owner Statements of Desig ed Undergroynd Storage Tank (UST`) Q ' <br /> and Understanding of and Compliance with UST �4e� s <br /> Facility Name: My Mini Mart Facility ID#: <br /> Facility Address: 1756 Wilson Way Reason for Submitting this Form(Check One) <br /> Stockton, CA. 95205 ®Change of Designated Operator <br /> Facility Phone#:(209)941-2264 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Mark R. Fairbanks Relation to UST Facility(Check One) <br /> Business Name(If different from above):Fairbanks Environmental Consulting ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (209)993-3298 cell, (209) 754-1636 office ❑ Service Technician ®Third-Party <br /> International Code Council Certification#:5243795-UC Expiration Date: 10/07/2006 <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Iftli ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Iftli ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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) wl 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): )) 6m I zl/) <br /> SIGNATURE OF TANK OWNER: t64 k j r Ci <br /> DATE: December 22. 2004 OWNER'S PHONE#: (209) 941-2264 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.gov/ust/contacts/eppa aeys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />