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San Joaquin County <br /> Environmental Health pepartmc0t <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209)46&3433 <br /> Ower Statements of Uesipated Underground Storage Tank.(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> L�acilatYl�awtlao: �. G<� _,�_...�..... Facility ID 0: <br /> Facility pddrossy (,f !1 `' Reason for Submitting this Form(Check 0-) <br /> -oma �'F �E� C3 Change of Designated Opetloor. <br /> Facility I?ham#: J 3''-il�' C� T upate Ccktificate Expiration Date <br /> lbea_i natal UST rfor s)-for th; Fac - <br /> PRIMARY _,_—, �. -. �_— �..�..�... <br /> msignatcd opeetaWs Name- - ! Reladoo to UST"Facility(Check One) <br /> Businew Name(If t>�itat from above): �j,., �c.„y lr a ❑ Owzarx CJ C3perator CJ Employee <br /> 0 Service Technician X Third-Party <br /> laesignatodOpceratoes Phone tt: - .Z_�-� <br /> International Godx council Certxftcation#: 4. <br /> Expiration 1Jatc: cp <br /> AVIT,RNATE 1 . _. <br /> Designated opepooes Name Retatian to UST Facility(Check tare) <br /> ployec <br /> Widnc"Name(Cfdtfemnr frum abmw): � 13 Owner t7 Operator 0 l marty <br /> Designated •s Phoma - -Sr ,� C3 Setvicc Tachaic;an "chird�Patty <br /> .,.� Code C ►eil CartifumdQu!!: ... Expiration Date: L9 <br /> pl'PFRNAT'R 2 <br /> NdTR02 orRelation to UST Facility(Check One) <br /> i+Tatne{!f di,'�i!t ent from above).' 0 Ocaner 0 taperator 0 .EmployeeQpctator,s a#: "" O Service Technician 0 'third-Party <br /> lnmmwupmt Code Council Cettifuxtiou#: Facpirntian Date: <br /> NOTE:THE LOCAL REGM ATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES To TMS <br /> U41 TION WITIM 30 DAYS OF THE CHANGE.. <br /> Ffor the facility indicated at the top of this page,the individual(s)listed above will <br /> gnated'UST Operator(s). The individuals)will conduct and document monthly <br /> ctions and annual facility employee training,in accordance with California Code of <br /> Re6yulations,title 23,qection 2715(c)-(fl. <br /> Furthermore,11 understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)appl Sable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print <br /> SIGNATURE OF TANK OWNER: r' <br /> RATE: i" OWNER'S PHONE 0* ^` lG� / <br /> November 2004 <br /> Id Wdbb:90 9002 8E 'Oac[ 'ON XtUd WONA <br />