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2009 05/04 12:01 FAX <br />+ SJEH Q 002 <br />RL4 <br />3f <br />.4�1 4. <br />MAY 0 4 2009 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />,1EA! TH DEPARTMENT <br />Owner Statements of Designated Undergrouad Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Naame: <br />Facility ID I: <br />adt ty Address: 139q0XM <br />M <br />Rcawn for Submiltis thin Pore► (Cheat Orr) <br />Cbsuge of Deaignsted Operator <br />Facility F%0" 4: <br />.01".ov <br />DmIptated Operew's Wow- David A. WWW& <br />Reladon to UST Fwility (Cheek One) <br />Service Technician <br />Hutto a Name (yd0kmrd jrant above): AfiordAlftst <br />Dw4p4W OnwaWsP►ow*!7 12 <br />Intenumowl Coda Council Cameadon b: 263 <br />Eupitsrion Date: 313M <br />a„>M x fiW <br />DeslpWW -a Pbom a: <br />Inftrndi.W Cjk Council can <br />ALTERNATZ <br />Btfatuess Name (rdt fnsntlrnn <br />DeOgnsfed OparaWs Phone /: <br />O2�EA. Nimsme <br />Affords -Test <br />209 744-0112 <br />s: 5263322 -UC <br />bawr40=4 Code Coweil Cee d000doa 0. <br />fle D. Nimmo <br />Aftvrds-Tat <br />209 744-0112 <br />5249115•UC <br />Ralatian b UST Facility (Check Orfs <br />Service Technician <br />nape: 213/08 <br />Rel m fn LMT Facility (C 7trck 0* <br />Service Techmician <br />Doe: 7/1/09 <br />1 certify that, for the facility indicated at the top of this page, the individuals) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and sanurtll OKility employee UukAn& in accordance with California Code of <br />Regulations, title 23, section 271 S(c) - (f). <br />MArMirmore, I nsderstand and am iia compliance with the requirements (statutes, <br />regulations, and local ordlaances) applicable to asdcrgroaad storage tanks. <br />NAME OF TANK OWNIR (Pbaw PeuO: 13 �✓ � N G^�I M � N' � �� <br />SIGNATURE OF TANK OWNER: IR S ► y V�� <br />DATIL:�9 %tQ LOR O'WNER'e room <br />NOTE: 1) SUBMIT THIS COMrLETED FORM TO THE LOCAL AGENCY (NOT THE STATE 'WATER <br />1tEt URMS COMMOL DOARD) RY JANUARY 1, 2Wx. 'THI LOCAL AGENCY LM 0 AVAR.ASLE <br />ATi www.watorboarda.ca.&vAlsdcontacts/cugo,pEys.html. <br />Z) NOTIFY THR LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION Wff1RN 30 DAYS <br />OF THE CHANGL. <br />November 2004 <br />TO 3Vbd Z d3DIl T8ft6Z8 91:60 800Z/Z1/18 <br />