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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> General Hospital -FA0000086 <br /> Facility Address: Reason for Submitting this or (check one) <br /> 500 W. Hospital Road 0 Change of Designated Operator <br /> French Camp, Calif. 95231 Xupdate Certificate Expiration Date <br /> cil1t on (209)468-6166 <br /> Designated LIST Operator(s) for this Facility <br /> Pr' <br /> Dsi n to er t is n an cllrath elation to UST Facility(check one) <br /> BusinessNaMfL. Valle I Under round Tank Monitorin Elowner ElOperator MEmployee <br /> D rvice Technician WThird-part . <br /> International Code Council Certification #:XX4141012575 Expiration Date: 11/13/2006 <br /> Alternate I <br /> Desi nated Operator's name: Relation to UST Facility(check one) <br /> Business E]Owner ElOperator EJEmployee <br /> D ervice Technician El ThirdT�_� <br /> International Code Council Certification #: Ex iration Date: <br /> Alternate 2 <br /> D Relation to UST Facility(check one) <br /> Business Name.- —E]Owner DOperator ElEmployee <br /> D ervice Technician EJ Third:22rty_ <br /> International Code Council Certification #: Ex iration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES 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 under round storage tanks. <br /> Name of Tank Owner <br /> or Owner's Agent(Please Print): <br /> Signature of Tank A <br /> Owner or Owner's Agent: <br /> Date: 12/30/2004 Owner'sPhone#-. (209)468-6166 <br />