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San Joaquin County <br /> Environmental Health Department <br /> 1868 E Hazelton Ave, Stockton, CA 95205 <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: FacilityID#: <br /> Facility Address: 14744, 1q &:::(- P/N AC Reason for Submitting this Form(Check One) <br /> �570 GI<-e)N CfF .Cl 52,05 ❑ Change of Designated Operator <br /> Facility Phone#: _ 3 3 ^"1DLS Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: r o ( G I'7a L Relation to UST Facility(Check One) <br /> Business Name(If different from above):f fA(r f N pC QpK p T ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Zpy b�fq- 9 5 6 ❑ Service Technician % Third-Party <br /> International Code Council Certification#: Expiration Date: s 1-2,11- <br /> ALTERNATE <br /> 2ALTERNATE 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-Party <br /> International Code Council Certification#: Expiration <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF A 44EUtIlVE' D <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> MAY 8 2013 <br /> I certify that, for the facility indicated at the top of this page, the individual(s) ageagwy <br /> serve as Designated UST Operator(s). The individual(s)will conduct and docs >1ip 09%NT <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): 5?7_22i64_7WN t�Nt Ft[�1 _�/fuD L /Jr5!12 is 7 <br /> SIGNATURE OF TANK OWNER: fz2cR� <br /> DATE: Fl�2d,3 OWNER'S P NE#: oZQ q-`I33-7ogS <br /> November 2004 <br />