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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 /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: USS (':&, -d- Facility ID#: <br /> FacilityAddress: ;?,4-iV Cx3 Reason for Submitting this Form(Check One) <br /> C: 95.1 Change of Designated Operator <br /> Facility Phone#: -1,_ . 3 .3/a ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 5 — Relation to UST Facility(Check Ore) <br /> Business Name(Ifdifferent from above): ,Tn ❑ Owner V�Operator ❑ Employee <br /> Designated Operator's Phone#: os . a(�-GaC��} ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5 `� -u C Expiration Date: P 3_�).a QD�- <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): S ❑ Owner _l Operator ❑ Employee <br /> Designated Operator's Phone#: _ J-j _ 0-v J ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent front above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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):YLCI_�, CCUXC� � U S ��e4ri Fe u ty, <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE 4: ly- QaOL) <br /> November 2004 <br />