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0 <br />69/21/2001 01:57 <br />209832518 <br />304 E. Weber <br />Telephone <br />Owner Statements of Desi <br />and Understanding <br />GRANTLINE BEACON <br />,� 1-13 <br />an Joaquin County <br />mental Health Department <br />e., Third Floor Stockton CA 95202 <br />19) 468-3420 Fax (209) 468-3433 <br />Underground Storage Tank (UST) <br />Compliance with UST Requiremen <br />ator <br />PAGE 03 <br />Facility Name: Facitir ID 4; Y <br />Facility Address: Reason for Subtnitting this f'' <br />(Check One) <br />El Change of Designated tor <br />Facility Phone #; _ ❑ Update Certificate ExpiDate <br />PRIMARY <br />Designated Operator's Name: <br />Business Name (!f differentfrom above): <br />Designated Operator's Phone # <br />International Code Council Certification a: <br />ALTERNATE i (Optional) <br />Designated Operator's Name: <br />Business Name (If'different from above) <br />Designated Operator's Phone #_ <br />International Code Council Certification k: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />NOTE: THE LOCAL REGULATORY <br />INFORMATION WITHIN 30 <br />this Facili <br />Relation to UST Facility (G <br />❑ Owner ❑ Operator <br />❑ Set -vice Technician ❑ <br />Expiration bate - <br />Relation to UST Facility (C <br />❑ Oromer ❑ Operator <br />0 Service Technician ❑ <br />Expiration Date' <br />Relation to UST Facility (Cl. <br />Cl Owner ❑ Operator <br />❑ Service Technician ❑ <br />Expiration Date: <br />i0i' MUST BE NOTIFIED OF ANY CHANGES <br />OF THE CHANGE. <br />I certify that, for the facility indicate at the top of this page, the individuals) listed <br />serve as Designated UST Operator( The individual(s) will conduct and document <br />facility inspections and annual fitcili employee training, in accordance with Califol <br />Regulations, title 23, section 2715(c (. <br />Furthermore, [ understand and al <br />regulations, and local ordinances) <br />NANIE OF TANK OWNER (Please Priv <br />SIGNATURE OF TANK OWNER: <br />I DATE: It5-- 1-2$ ' <br />Orie) <br />Employee <br />One) <br />Employee <br />One) <br />Employee <br />ird-Party <br />in compliance with the requirements (statut , <br />plicable to underground storage tanks. 1 <br />C. A, --n l'14/-\ <br />NER'S PHONE #: 40 —/ b <br />THIS <br />ve will <br />Code of <br />r2004 <br />