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a 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 /> FacilityName: M6edl L-Azur U4 Facility ID#:279 k <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> a r7 L 4—)* ❑ Change of Designated Operator <br /> Facility Phone#: - 4 7, 3 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: LL— (N Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): sj X ❑ Omer ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 1—,3()-- <br /> O-- ' (T . ❑ Service Technician 9L Third-Party <br /> International Code Council Certification#: Expiration Date:tl' V—ded i <br /> ALTERNATE i O bona! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): 101 ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician 51 Third-Party <br /> International Code Council Certification#: 161 Expiration Date: 0 0 1 00 <br /> - <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 L <br /> SIGNATURE/OF TANK OWNER: ,_� <br /> DATE: ! _ -7 OWNER'S PHONE#: -7,33 7 <br /> November 2004 <br />