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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: J & L Market Facility ID#: FA0000110 <br /> Facility Address: Reason for Submitting this Form (check one) <br /> 8125 S. E1 Dorado St. El Change of Designated Operator <br /> French Camp, Calif. 95231 Ey�Update Certificate Expiration Date <br /> Facility Phone #. (209)982-5084 d I <br /> Designated UST Operator(s) for this Facility <br /> Primary <br /> Designated Operator's name: Dan Mcllrath Relation to UST Facility (check one) <br /> Business Name: valley Underground Tank Monitoring ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: (209) 476-1805 ❑ Service Technician U Third-party <br /> International Code Council Certification #:XX4141012575 lExpiration Date: 11/13/2006 <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification #: Expiration Date: <br /> Alternate 2 <br /> Designated Operator's name: Relation to UST Facility (check one) <br /> Business Name: ❑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 <br /> THIS 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 serve as <br /> Designatd UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> Name of Tank Owner <br /> or Owner's Agent(Please Print): Jim Fisk <br /> Signature of Tank <br /> Owner or Owner's Agent <br /> Date: 12/17/2004 Owner's Phone <br />