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San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Fax (209)468-3433 <br /> 2005 NAR 39 <br /> I Pl, ,r. <br /> Owner Statements of Designated Underground Storage Tank (USfA Q98rator <br /> and Understanding of and Compliance with UST Required lg7y pNNENOUDUA IU T y <br /> Facility Name: Facility ID#: -1 0 �N T <br /> Facility Address. /f w �a e� ��y Reason for Submitting this Form(Check One) <br /> I ❑ Change of Designated Operator <br /> Facility Phone#: �(f ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: ( o ra Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): New 66 ?6yV,(UjK ❑ Owner ❑ Operator t6r'Employee <br /> Designated Operator's Phone#: l u 2O —p ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: I Expiration Date: <br /> ALTERNATE r(Optional) <br /> Designated Operator's Name: MAO (r � Relation to UST Facility(Check One) <br /> Business Name(Ifdiiferentfrom above):NS� U0 ❑ Owner ❑ Operator 1�ployee <br /> Designated Operator's Phone#: 11W q/L r — POO <br /> O ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: XX + D r Expiration Date: �p <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): W(I(J ❑ Owner ❑ Operator 8' Employee <br /> Designated Operator's Phone#: — ((/(/ ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: 07 <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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) 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, I understand and am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to under"rgroou" ,ndy}storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: �i(� /� <br /> DATE: OWNER'S PHONE#: ITl ) — O 1 U <br /> November 2004 <br />