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San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />V <br />E Vit�vil!(� j <br />Owner Statements of Designated Underground Storage Tank (UST r A` <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />FacilityID #: <br />Facility Address: L S G{- c <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 0 4 P- 3 I -A l �— (® <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: P 1 C 6 L i to <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 #: 6 CX r1 ` <br />International Code Council Certification #: L[ a� L—( <br />Expiration Date: �_ f PWL <br />ALTERNATE 1 (Optional) <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 (Optional) <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 d fferent 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 />1 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): L -i C -- <br />SIGNATURE OF TANK OWNER: <br />DATE: / J, 7- U OWNER'S PHONE #: q S- � `6 <br />November 2004 <br />