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I`VJ DE POL Fax: 20946619113 Jan 9 2012 15: 13 P. 05 <br /> San Joaquin County <br /> Environmental Health Department <br /> j 600 E. Main Street Stockton CA 95202 <br /> telephone(209) 468-3420 Fax (209) 468-3433 <br /> I <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nam <br /> rive C� c/1^ Facility ID#: <br /> Facility Address, <br /> / Reason for Submitting this Form(Check One) <br /> I1 Change ofDcsignated Operator <br /> Facility Phone#: ❑ Updatc Certificate Expiration Date <br /> l <br /> { <br /> Desiznated UST Qperator(s) for this Facility <br /> PRIMARY <br /> Designated operator's Name: ! (ft�L Relation to UST Facility(Check One) <br /> Business Namc(If different from above): f - ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Q ictvice Technician ❑ Third-Parry <br /> International Code Council CertLcation#: 2. 3 3 w Expiration Date: 7 <br /> ALTERNATE I dofral <br /> Designated Operator's Namc: <br /> ��c?� Relation to UST Facility(Check One) <br /> Business Name(If different from above): 4 e ❑ Owner ❑ Operator 13 Employee <br /> � <br /> Designated Operator's Phone#: _ I� Service Technician in Third-Party <br /> International Code Council Cert}fication 0:S2 Z 2—l�1 G Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: L/C t y�lG Relation to UST Facility(Check One) <br /> Business N=e(If dii fereni from above): O ❑ Owner ❑ Operator Q Employee <br /> Designated Operator's Phouc#i <br /> L�rvicc Technician :3 Third-Party <br /> International Code Council Certification#: — Expiration Date: 'L. <br /> NOTE:THE LOCAL RE(gULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I <br /> I certify that, for the fa l ility indicated at the top of this page, the individual(s) listed above will <br /> serve as Designated U T 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) - (fl. <br /> Furthermore,Y unde stand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NANTE OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DA'Z'E: 1.V f � � � OWNER'S HONE 4: <br /> s <br /> November 2004 <br /> f <br />