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FROM FAX NO. r. 24 2003 02:21PM P1 <br />----- <br />----- <br />---- <br />P-02 <br />San Joaquin County <br />Environments] Health Departmeaf - <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) Operatoi <br />and Understanding of and Compliance with USTRequiretrients <br />Facility Name: <br />Facility Addrun: Facility ID #! <br />4_ <br />RedxOti for Submitting this Forin (C'hecA (),t� <br />Tr -,q-, 64 7 <br />Facility Photic <br />Update Cenificsite �'xpjrjjtjon nate <br />DMiggnated-US3:.09MLtorjsj for this Fa <br />Business Name (If &ffurentfram aboj,e)-, <br />Dc5ignated operator's Phone ot: 92-6, IP?Z- 2979 <br />Ititcrastional Code Council Certification #: <br />ALTEP-NAVE I CO <br />Desipatod Opcnitor's Name -4 <br />Business Natric (1fdi0mnjfi-&,n above): <br />Designtitcd Operator's Phone #: �-jcj <br />international CWc Council 'C;;f,.tion <br />Relation to UST Facility ((,heck One) <br />Q Owner 0 Operator [: E , <br />C1 Scrvice Technician -fir-'Third-per,. <br />k9pimhon Date: <br />Mation to UST Facility (check otw) <br />0 O%VW 0 Operator Cl Einp!Oyce <br />0 smiccTechnician .2r,linni-Parry <br />Expiration <br />Desipatcd Operator's Nunc: Relation to UST Facility (Check One' <br />.1 <br />Business Name (if OffereNfrom 01yu W): 0 Owner 0 Operator a <br />Designated Operator's Phone 0 Service Technician 0 Third -Party <br />Intmational L:ode Cmucil Certification N: <br />Expirmion nate: <br />.NOTE: THE LOCAL REGULATORY AGENCY MUST BE NorFIEI) 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) lisicd above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and doculnent monthly <br />facility inspections and annual facility employee training, in accordance with California ('ode of <br />Regulations, title 23, section 271 5(c) - (t). <br />I 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 Prijit); Sz <br />SIGNATURE OF TANK OWNER: <br />r)AT F. - <br />OWNER'S PHONF <br />2 <br />