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FROM:TO:4683433 07/28/2015 07:35:00#20141 P.002/002 <br /> JUL <br /> Sun Joaquin C'ounty <br /> Environmental Health Department ��1VlRUlVI�I�IT��.. <br /> 600 E. Main Street Stockton CA 9.5202 <br /> Telephone(209)468-3420 Fax (209)468-3433 <br /> Owner Statements of Designated Underground Storage Tank (LIST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> t acility Narrtc; F'�tcility It)#: <br /> Pucility Address: <br /> I(CWSOn(itr Subntitting this Forin(Chat 8111•) <br /> a SOrA,�ti+ 1X��"► �R�G „_ P�t,.Chaltge of Designated Operetor <br /> Facility hhunc f<; ❑ Update(l'ertilic:gc Gxpiruiion Dale <br /> Designated UST Operators for this Facility <br /> PRIM ARI' <br /> r_ _.... <br /> ...,.. . <br /> .VBUNiness'Narne <br /> atal Operator's Nunn: RelationIo ST Facility(,()eek he) <br /> {If<iJjcrrnt/ro„r ❑ >Wner yOporator [] tnpluyc <br /> 2 �rvicc•Iechnichn Ll Third-1'ttrty <br /> tional <br /> Code Council Cellitication#; 040 5 7 ,, t{xpll`dtiorl 17utC; Q� <br /> ........... <br /> _..� ................ <br /> At:I'ERNA'l- I(o tionul <br /> Designated O}x ratiu''s Numc: A� y Relation to IJ1,1 I'aciiity(('het k One) <br /> Husiness Numc(l/rl([/itYrnl ftpgt ❑ Owner ❑ Operator t5 f,'.niployee <br /> T)c+iguated Oper;tutr's Thune J{: <br /> EJ Service I'cehaician 0 Third-Party <br /> Internatiomal Code Council Certification#:,�. li\plratiun D211c: � - <br /> AI.T'ERNA74,:2 (Optional) <br /> Designated Operatur's Name: Relation to IIST t'aciiity((.'hark t..)„c•) <br /> Il•llilr es%Nanic(if(jrJ ,l-L-tu Jrtult above): ❑ Owner ❑ Operator ❑ t:mpinycc <br /> Dcskgntited Operitot's Mimic ti: T " ❑ Service'I'celinician 0 Third-INrty <br /> Inlernmtiuuul Code Council C ertilication 0: _ Expiration Date: <br /> NOTE:THE LOC. ..,REGL1LA'r0RY AGENCY MUST RF,NOT IFIF )OF ANY CHANGE'S TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the lop ol'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, 1 understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> NAW OF TANK OWNER(Please Print); _ <br /> SIGNATURE OF'YANK OWN UR: -..� <br /> DATE: '+t;O/SOWNER'S PHONE#: <br /> November 2004 <br />