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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 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Sk art Mr. Cafe Facility ID#: <br /> FaciliAddress: Reason for Submitting this Form(Check One) <br /> 713 V El Dorado Street <br /> Stockton. CA 95202 M Change of Designated Operator (Add` 'ternate) <br /> Facility Phone#: Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: JUSEPH BAGLEY Relation to UST Facility(Check One) <br /> Business Name(If&fferentfromabove): BAGLEY ENTERPRISES IN .❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-367-4800 ❑ Service Technician XX Third-Party <br /> International Code Council Certification#: 5297791—UC Expiration Date: 11/11/10 <br /> ALTERNATE 1(Optionap <br /> Designated Operator's Name: JESSE BERUMEN Relation to UST Facility(Check One) <br /> Business Name(If&ffereW from above): BAGLEY ENTERPRISES IN .❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 209-367-4800 ❑ Service Technician XXThird-Party <br /> International Code Council Certification#:8014628—Uc Expiration Date: 11/11/10 <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 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): Skymart Enterprises, LTD <br /> 4j:7Dv Cuv �r t<s TDc) /=tit2 <br /> SIGNATURE OF TANK X,? R: � � - Q Sk YM VAC; <br /> DATE: /t Ll t&OO P OWNER'S PHONE#: � ��1�'�7- `,4�0 U <br /> November 2004 <br />