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San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 NQ 3 0 2004 <br />Owner Statements of Designated Underground Storage Tank (UST))�pei atpr <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: f,/% i i/iUS 'G <br />FacilityID #:y— <br />Facility Address: L Z-/ Z-1 M 5 SGC �(� <br />X� n v ��. <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 0 U a 3 -t l 2- $ (� <br />Designated UST Operator(s) for this Facility <br />PRIMARV <br />Designated Operator's Name: tO 1 C 6 i(:3 v lr %. 0 0'�' <br />Relation to UST Facility (Check One) <br />t�Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifderent from above): <br />Designated Operator's Phone #: a U ,�N 5 C) 1� c,, rc� <br />International Code Council Certification #: �'� i_j 3-7 1--( _ <br />Expiration Date: l U . ) �- , a W (n, <br />ALTERNATE. 1 (Ontionah <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Untionat) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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): �M Q %�� c� . ^ <br />DATE: , �, 7- 0 � OWNER'S PHONE #: <br />SS). o�(,'�( <br />November 2004 <br />