Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />T 1 h (209) 468-3420 Fax (209) 468-3433 <br />G��SGFVN/L�Lo) <br />JAN 1 3 2010 <br />e ep one ENVIRONMENT HEALTH <br />Owner Statements of Designated Underground Storage Tank (USIFaRTXpVICES <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: q)zrraFacility <br />ID #: <br />Facility Address: 130 S. Wilson Way <br />Stockton Ca. 95205 <br />Reason for Submitting this Form (Check One) <br />A Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209)466-6633 <br />Desienated UST Operators) for this Facility <br />DD 1FXA A D V <br />Designated Operator's Name: Dan McILrath <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ;( Third -Party <br />Business Name (If different from above): 1 Py lJndergrniind Tank <br />Designated Operator's Phone #: (209)649-8956 <br />International Code Council Certification #: <br />Expiration Date: 2 0 2011 <br />f ATL' 1 //1..1:nxn/l <br />ALaa'Jly �A it. a <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 /Ontianal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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 underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE OF TANK OWNER: <br />DATE: — 7 -/L7 OWNER'S PHONE #: <br />November 2004 <br />