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' i0ec 31 04 02: 13p Can a 's Car Wash (209) 948-1464 p. 3 <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 F. 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 Regitirements <br /> Facility Name: Y% r Facility ID t1: 64-000<3- '2 <br /> FacifiV Address: p`, Reason for Submitting this Form(Check One) <br /> p� 11 �1' TUf r. R—Change of Designated Operator <br /> Facility Phone##: ZP9 - ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRI N•IARY <br /> Designated_Operator's i`1ame: j qy����,•�M Relation to UST Facility(Check One) <br /> Business Name(If elierentfr•ow above): -�- ❑ Owner ❑ Operator O Employee <br /> Designated Operator's Phone#I: C1 ' ❑ Service Technician 00* I'hird-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to Us'r Facility(Check One) <br /> Business Nance(if different frow aliure): ❑ Owner O Operator ❑ Employee <br /> Designated Operator's Plione fl: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification n: A Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Nantc: � Relation to UST Facility(Check One) <br /> Business Name(Ifrliffcrent from above): _ ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 11: ❑ Service Technician , ❑ Third-Party <br /> International Code Council Certification 11; Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO'1'1IIS <br /> INFORMATION WI'T'HIN 3Q DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,the individuaI(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 Califonzia Code of <br /> Regulations, title 23, section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with theregairements(statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAIME OF TANK O)VNER(Please Print): l Caneno <br /> SIGNA`CU)C2.I+,O2�T.4.tNIst���1'�i;i2:���' <br /> DATE: �o�- -0 OWNERIS PHONE ft: -�fo --dot cyC <br /> November 2004 <br />