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03/17/2002 20:19 18007697413 PAGE 01 <br /> Sao 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 Tarl,. (UST) Operator <br /> and Understanding Of and Compliance with UST Requirements <br /> FacilitYName: _�._ T aAIF- Facility ID 4: <br /> Facility Address:�G ,�ya. S1 _ I A Y-�a vt oed Reason for Submitting this Form(Check One) <br /> f gni C N a Cbt. q5.2?/ ❑ Change of Designated Operator <br /> Facility Phone 0: <br /> � s ❑ Update Certificate Expiration Aate <br /> D_ esignated UST OneratOr(S) for this Facility <br /> PRIMARY <br /> Desigttated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdijjerent fm n above).- ❑ Owner ><Operator ❑ Employee <br /> Designated Operator's Phone#:_ q&,-3-7/— ;, :57Q O Service Technician ❑ Third-Party <br /> International Code Council Certification 9: Expiration Dalc: <br /> ALTERNATE 1 (O Hon al <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1fdderc a fivm above): O Owncr ❑ Operator ❑ Employee <br /> Designated Operator's 11nonc n: ❑ Service Technician ❑ Third-Party <br /> International Code Council Corti fication N: Expiration Date: <br /> AI.TF,RNATE 2 (Optional) <br /> Designated Operator's Namc: Relation to US'r Facility(Check One) <br /> Business Name(1fdl,(rerent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification p: Expiration Ditto: <br /> NOTE:TETE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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(e)- (1). <br /> Furthermore,T 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 : r"' &I ` 4 <br /> SIGNATURE OF TANK OWNER: !` <br /> DATE: —/_0T OWNER'S PRONE#: <br /> r&w,,05 O ;L TaoV ouEtP, cr-96e¢ <br /> November 2004 <br />