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SEP � � 200 <br /> Owner Statements of Designated Underground Storage Tank (UST) O for <br /> and Understanding of and Compliance with UST Requirements-1 PERMIMENT HEALTH <br /> /`'' PERMIT/SER111rE <br /> Facility Name:d c>C h WN i 1q1 Pr Foodd Facility ID#: <br /> Facility Address:2185 Fremont St. Reason for Submitting this Form(Check One) <br /> Stockton, CA. 95205 ®Change of Designated Operator <br /> Facility Phone#: (209) 937-0195 1 ❑ Update Certificate Expiration Date <br /> esi nated UST Operator(s)for this Facilitv <br /> PRIMARY <br /> Designated Oper or's Name: Mark R. Fairbanks Relation to UST Facility(Check One) <br /> Business Name&Cdifferentfrom above):Fairy onmenta/Consulting ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone : 09)993-3298 cell, (209) 754-1636 office ❑ Service Technician ®Third-Party <br /> International Code Council Certification#:5243795-UC Expiration Date: 10/07/2006 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ 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(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Parry <br /> International Code Council Certification#: Expiration Date: <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): O—n i1 Iz COC,�'1 <br /> SIGNATURE OF TANK OWNER: k&n:�az <br /> DATE: Auqust 25, 2005 OWNER'S PHONE#: (209) 937-0195 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: %;ww.waterboar:".,;.cn.._=ov/usticontacts.'curn <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE-CHANGE. <br /> November 2004 <br />