Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street 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: plc/ d (" /j'J Z��C- Facility ID <br /> Facility Address: <br /> `f 0�M1'F� AV JZ Reason for Submitting this Form heck One) <br /> I+r WTD CA ft5a26 1K Change of Designated Operator <br /> Facility Phone#: g f ❑ Update Certificate Expiration Datc <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 'AAP.ez , V1q�Z— Relation to UST Facility(Check 6 ne) <br /> Business Name(Ifdifferentfrom above): ❑ Owner Q Operator Q Employee <br /> Designated Operator's Phone tl: jo 6 ❑ Service Technician Thir -Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: Relation to UST Facility(Check C ne) <br /> Business Name(/fdiQerent from above): D Owner O Operator Q Enployer <br /> Designated operator's Phone#: ❑ Service Te,ctmician ❑ Third-Party <br /> International Code Council Certification#: Expiration Dale: <br /> .ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check e) <br /> Business Name(If different from above), ❑ Owner O Operator ❑ E nployec <br /> Designated Operator's Phone#: O Service Technician D Thir -Party <br /> International Code Council Certification B. Cxpiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO I HIS <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 abov will <br /> serve as Designated UST Operator(s). The individual(s) will conduct andidocumeat tno hly <br /> facility inspections and annual facility employee training, in accordance with California ode 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): Oz- �Y/!/ <br /> SIGNATURE OF T1 LANK OWNER: <br /> DATE: aT —anlo OWNER'S PH E H. <br /> November 004 <br />