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JAN-06-2006-THU 12;38 PM <br />P. 006 <br />Ilec 22 04 03:59p Franzen Hill 5596881487 p.2 <br />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: Food 4 Less <br />Facility ID #: N-4608 <br />FaciliryAddress:3408 Manthey St. <br />Stockton, CA <br />Rea son for Submitting this Form (Cherk One) <br />Jai Change ofDesignated Operator <br />0 Update Certificate Expiration Date <br />FacilityPhone #:858-0101 <br />Designated UST Operator{s) for this Facility_ <br />i il:i Mti1:1;>t'1 <br />Designated Operator's Namc: Franzen -Hill Relation to UST Facilily (CnerkOne) <br />Bus+^css Names (l,�di!Tc-e�: <rom ohrvrl ❑ ^„ :;_7 _ Opera:o: C Er•,p'.o c_ <br />I Designated Operator's Phone #; 559--688-2977 )6 Service Technician X Third -Party <br />Intemational Code Council Certification #: 5246124—UC Expiration Date: 11-19-06 <br />A1.TFRNATF t /nnrrntiell <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employer <br />❑ Service Technician A Third -Party <br />Business Namc (Ifd fferenr from above): <br />Designated Operator's Phone #: <br />International Codc Council Certification #: <br />Expiration nate <br />ALTE" it: z Wvfxoaan <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />O Owner ❑ Operator ❑ Employee <br />❑ Service Technician O Third Party <br />Business Namc(1fdyyerenefromabove): <br />Designated Operator's Phone #: <br />International Code Council Gertifimion M <br />Expiration t)atc: <br />NOTE: TKE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CiiANGE. <br />T_J_-.1-_,_._r.1. d.. '_�r__��. _+i �,r_. � . •.• <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 lunderground st a tanks. <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURE OF TANK OWNER: C V <br />DATE: �. � �,3 _ b _ OWNER'S PHoiY>; : _6c�Q5k 3 I ` — <br />