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San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (20014658-1,170 FaY (209) 468-3433 <br />i <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: l�4 e Li <br />Facility ID <br />Facility Address: <br />*& 0 <br />Reason for Submitting this Form (Check One) <br />International Code Council Certification #: 5 ;k t4 V1 "15 - 1.1 ci <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: GNM P-- t 5-- <br />Relation to UST Facility (Check One) <br />VU Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent from above): <br />Designated Operator's Phone #: t,l U to -- S g t(p <br />International Code Council Certification #: 5 ;k t4 V1 "15 - 1.1 ci <br />Expiration Date: <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 (Ifdifferent front above): <br />Designated Operator's Phone #: <br />International Code Council Certification th <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 (lfdifferent from above): <br />Designated Operator's Phone #i: <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): G Vif el <br />SIGNATURE OF TANK OWNER: j L <br />U NJ <br />DATE: 2/ OWNER'S PHONE #: <br />November 2004 <br />