Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department <br /> 600 E.Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(2 09)468-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: MCA f Facility ID#: <br /> Facility Address. Reason for Submitting this Form(Check One) <br /> Ma in te-ca '75; 12k G "ange of Designated Operator <br /> Facility Phone#: S— 11 c;ee 0 Update Certificate Expiration Date <br /> Designated UST Or&rator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: t Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom�above): 0 Owner 0 Operator 11 Employee <br /> Designated Operator's Phone#: a 0�— 8 RCS—LI 4G (0 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1(QpdonaO <br /> Designated Operator's Name:aaran 0- bkillm Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): Quick cto )Ma& o owner o operator 13 Employee <br /> Designated Operator's Phone#: a(n— e)—C.� 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 fflpdonaf) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 11 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): <br /> SIGNATURE OF TANK OWNER: IrWA" <br /> DATE: 01114 L3 —OWNEWS PHONE#: M1 :3 Z-2 ® 6e?i 3 <br /> T-T <br /> November 2004 <br />