Laserfiche WebLink
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 Narre: ELVIFacility ID#: <br /> Facility Add.-ess: Reason for Submitting this Form(Check One) <br /> j�1�t3 W• `tom']-/� �C� �a ����K�� ❑ Change of Designated Operator <br /> Facility Phone#: c,!3 ) ��- 13 Update Certificate Expiration Date <br /> `t —-- <br /> Designated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdi rerent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> Internationa;Code Council Certification#: Expiration Date: <br /> ALTERNATE l (Optional) <br /> Designated Operator's Name: j GJ< � n Relation to UST Facility(Check One) <br /> Business Name(If di.Jfereni from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: l) 9 3 &0 ❑ Service Technician Third-Party <br /> International Code Council Certification#:5a L '7 y-?.—u L Expiration Date:0C,+ <br /> r �v <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility((,heck One) <br /> Business Ne.rne(If dierent from 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 1:hat, 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): �.�� �%�l�✓-� A S] N &H <br /> SIGNATURE OF TANK OWNER: rel 1e1 � ZIA <br /> DATA: ) 1 ��'� OWNER'S PHONE 4: XL o <br /> November 2004 <br />