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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 DEC 2 9 2004 <br /> LNVlH()NNiENI HEALTH <br /> Owner Statements of Designated Underground Storage Tank (USpgWES <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> t s 0,0 0 Change of Designated Operator <br /> Facility Phone#: Z Q ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) For this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifd Jferent from abol,e): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician Third-Party <br /> International Code Council Certification Expiration Date: <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lfdii ferent 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(Ifdiferent 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 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): G� <br /> SIGNATURE OF TANK OWNER: <br /> i <br /> DATE: L2, OWNER'S PHO . 73 <br /> November 2004 <br />