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JUL/23/2012/MON 09;33 AM BANKV THE VEST FAX No.209462163 P.001/001 <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Strdet Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-5433 <br />Owner Statements of Designated Undt rg round Storage Tank (UST) Operator,' <br />and Understanding of Mad Compliance with UST Requirements <br />Facility Name: E7 �/ <br />Facility ID #; <br />l?aciLity Address: $� ~ Y0.5 a,,, f,es� <br />ill 7 d <br />Reason for Submitting this Form (Check One) <br />;K Change of Designated Operator <br />13 Update Certificate Ex iratlon Date <br />Facility phone #: <br />Designated UST U erator s for this Facility <br />PRMIARY <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Business Name (Ifdifferentfromabove): .ej , ' 1"'t(` rfi Owner ❑Operator 13 Employee <br />Designated Operator's Phone #: ZAq (Q(D q qajG ,K Service Technician ❑ Third -Party <br />International Code Council Ccrtification #: 92S 13-042, Expiredon Date• f 215 —_2014/ <br />ALTERNATE 1 a tio„a1 <br />Designated Operator's Name: Relsdon to UST Facility (Check One) <br />Business Nannie (tfdri ferent from above): ❑ Owner ❑ Operator ❑ r=ploy** <br />Designated Operator's Phone #: ❑ Service Technician ❑ Third -party <br />Intornational Codc Council Certification #: Expiration Date: <br />FAIVID,+ery MDMIAMM ,r, h <br />Designated Operator's Nano; <br />Rslation to 019T Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdifferent from above): <br />Designated Operator's Phone #; <br />International Code Council Certification #; <br />Expiration Doc: <br />NOTE; THE LOCAL REGULATORY A,GZNCit MUST BE NOTIFIED OF ANY CRANGES TO THIS <br />'OXZi12ATION WITHIN 30 DAYS O)F TRE CHANGE. <br />I certify that, fox the facility indicated at the top of dais page, the indi'vidtial(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 accordanoo with California Code of <br />Regulations, title 23, section 2715(0) - (f). <br />Furthermore, X understand and am is compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to undergrgEndstorage tanks. <br />NAMS OF TANX OWNER (PIease Print): — <br />SIGNATURE OF TANK <br />r <br />DATE: �.. �/ I —/ % "� ^ _ .� OWNER'S PHONE #t 'rS< 6goq J577-6 000 <br />r <br />November 2004 <br />