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San Joaquin County <br />Environmental Health Department <br />600 E. Main Street 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:(rn r I` <br />Facility ID #: <br />Facility Address: <br />! t y� <br />Reason for Submitting this Form (Check One) <br />'asChange of Designated Operator <br />❑ <br />❑ Update Certificate Expiration Date <br />Facility Phone tanct I - 15-5 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: —T0'r r <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Party <br />Business Name (lfdierent from above)_ <br />Designated Operator's Phone #: _ <br />International Code Council Certification #: b <br />Expiration Date: n <br />ALTERNATE I (Optional) <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 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Ihird-Party <br />Business Name (Ifdierent 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 />1 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): Q�KL-C (Dy-E'C_(2-S <br />SIGNATURE OF TANK OWNER: <br />DATE: y 1 b Z 3 OWNER'S PHONE #: <br />November 2004 <br />