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San Joaquin County <br /> Environmental Health Department <br /> �9 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> elephone (209) 468-3420 Fax (209) 468-3433 <br /> -4 <br /> � G> <br /> Owner Statements�'of Designated Underground Storage Tank (UST) Operator <br /> and' Understanding of and Compliance with UST Requirements <br /> Facility Name:Lobi 4 L I L"'y Faciiity ID#: pf o o©3 e-q <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> Ij �� � �" 'S� e( Change of Designated Operator <br /> Facility Phone#: off- 333— 1019 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: _0-fll/ y i'V Relation to UST Facility(Check One) <br /> Business Name(If different from above): `Z, S I3I'�i®� ❑ Owner n Operator L. Employee <br /> Designated Operator's Phone#: ❑ Service Technician J9 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1(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 /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check Ore) <br /> Business Name(If dii ferenl 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 RE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> Ficertify 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): k ao/vl <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 'Z� c'� OWNER'S PHONE#: 0L <br /> November 2004 <br />