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Owner Statements of Designated Underground Storage Tank (t1 LT) 6 tb r <br /> and Understanding of and Compliance with UST equi men <br /> DEP <br /> Facility Name: SJ Genaral HospitalFacilit I®#:FA0000086 i �3 ,, <br /> Facility Address: Reason for Submitting thiiForm ck one <br /> 500 W. Hospital Road F1 Change of Designated Operator <br /> French Camp, Calif. 95231 Update Certificate Expiration Date <br /> Facilit Rhone : (209)468-6166 <br /> Designated T Operator(s) for this Facility <br /> Prima <br /> Desi nated Operator's name: Dan Mcllrath Relation to UST Facility(check one) <br /> Business Name: Vall2y Underground Tank Monitorin ❑Owner ❑Operator ❑Employee <br /> Designated.,Operator's Phone #: 209 476-1805 ❑ Service Technician ArThird- a <br /> International Code Council Certification #:XX4141012575 Ex iration Date: 11/13/2006 <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility(check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> DesignatedOperator's Phone ❑ Service Technician ❑ Third- a <br /> International Code Council Certification #: Ex iration Date: <br /> Alternate 2 <br /> Designated Opera es name: I Relation to UST Facility(check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Desi hated Operator's Phone #: ❑ Service Technician ❑ Third- ?q <br /> International Code Council Certification : Expiration Date: <br /> Note.THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANCES TO <br /> THIS 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 serve as <br /> Designatd UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715(C) -(F). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, regulations, <br /> and local ordinances)applicable to undo round storage tanks. <br /> Name of Tank Owner - AA, <br /> or Owner's Agent(Please Print): C"d4 <br /> Signature of Tank <br /> Owner or Owner's Agent: <br /> Date: 12/30/2004 Owner's Phone*: (209)468-6166 <br />