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Jul 21 08 09;25a� 209-367-5424 p.2 <br /> 1 <br /> 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: 1LYMAP:-r LTD Facility ID#: <br /> Facility Address: '-1 t 3 T4. FL 00Rgpp0 g; Reason for Submitting this Form(Check One) <br /> A S207- &-Gange of Designated Operator <br /> Facility Phone 9: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: �S'tTl{ (y4£ Relation to UST Facility(Check One) <br /> Business Name(If&ffere"I from above):� C0 Owner 13Operator ❑ Employee <br /> Designated Operator's Phone#: ti 47 p ❑ Service Technician OV'Third-Party <br /> International Code Council Certification#: 52q r17q 1 , UC Expiration Date: KCQC b►eEQ Zf 260 <br /> ALTERNATE I(Qpliona4 <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If t*fferenl from above): Cl Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> international Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Ophonal) <br /> Designated Operator's Name- Relation to UST Facility(Check One) <br /> - i <br /> Business Name(Ifdifferentfron above): G Owner ❑ Operator ❑ .Employee I <br /> Designated Operator's Phone 9: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification H: 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 /> sense as Designated UST Operator(s)- The individuals),Mll conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance urith 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): D!f/q M <br /> SIGNATURE OF TANK OWNER: <br /> DATE: {7ly/ 0 OWNER'S PHONE M. <br /> November 2004 <br />