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0 0 <br /> San Joaquin County RECEIVED <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 j U N 2 9 2012 <br /> Telephone(209)468-3420 Fax(209) 468-3433 <br /> ENVIRONMENTAL <br /> Owner Statements of Designated Underground Storage Tank (UST) Op <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: SA&j f0A&u G L Ik L Facility ID#: <br /> Facility Address: SW Ljg4,r RlD. Reason for Submitting this Form(Check One) <br /> VA94X44 Z Rill CA Q 5 Z 3 J Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: :37ISSfr.. Ja9�P_44#"9#j Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician W'*Fhird-Party <br /> International Code Council Certification#: [r®p 5-7& 35' 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 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 /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> 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 <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):S $SL t50- S S 6 X_ sos WCX1jG8A1WjWe' <br /> SIGNATURE OF TANK OWNL Cfaam $j' <br /> DATE: ®ro`2 � �I Z OWNER'S PHONE#: (�OR) 36-7-4eoa <br /> November 2004 <br />