Laserfiche WebLink
San Joaquin County 0 <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />Owner Statements of Designated Underground Storage Tank (UST) O•, • <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: CNNVA14j, Ap6F <br />Facility ID #: Q&710%67 <br />Facility Address: nth �r 4 <br />�✓ <br />Reas n for Submitting this Form (Check One) <br />�.`�, � (� <br />Change of Designated Operator <br />Facility Phone #: e 11%3_153;370❑ <br />Update Certificate Expiration Date <br />Designated UST Operators) for this Facility <br />usl <br />Designated Operator's Name: ® 1r , <br />Relation to UST Facility (Check One) <br />Owner ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Party <br />Business Name (Ifdfferent from above):—Celsj'n❑ <br />Designated Operator's Phone #: ( 0 — 004, <br />International Code Council Certification #: 514 <br />Expiration Date: 10/1 <br />ALTERNATE l (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 different 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 individuals) 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 <br />DATE:SIGNATURE OF TANK OWNER: AwnnA &6�� <br />.,.?-CoLk OWNER'S PHONE <br />November 2004 <br />