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I .1I.1G1 <br />UNDERGROUND STORAGE TANS{ SYSTEM <br />S'TATE1VlE OF DESIGNATED l)'ST OPERATOR A" <br />UND _ ,G Q (W)COMPLIANCE LIANCE WITH UST REQUIREMENTS <br />For usa by (Jntdncs Member Agen c'Ies or where approved by your Local Jurisdiction <br />fh4►1 t t; 77 do .23, Piv. 3, Ch. 16 Cal fornia Cuda ojltegr latiors (CCR) <br />PACILITY NAM13 r•ACU-IT r PHONE -- <br />CRLLC #270644XN JOAQUiN COUNTY avq ) q7g — l sae. <br />BAIYal nNIUS:aTAI_ <br />T+ACILITY SITE ADDRESS HEALTH DEPARTMENT Cl,ry <br />1469 E. HAMMIER LANE STOCKTON <br />R msoN FFR sijam mqG mus FORM (Chuck owe); 0 CNange of Designated Oi7c1'ator Lj Update of ICC Cesrtiflastion rixpimzion Date(s) <br />PRIiMARY DESIGNATED UST OPERATOR FOR TIT IS FACILITY <br />DESIONNI'SO OPERATOR NAM1 Virginia Fulgaro RM ATION 7-0 UST FACIl.rry (Check 0)w) <br />BUSINESS NAME (1fd ffe,eneh&, ar m)! Tank -Tek Environmental Corp. ❑ ow>ner ❑ (vommr ❑ Employee <br />DESIGNATED OPMATOR PHONE: (707) 4+46-6161 ext. ❑ Service'T'cchnidan ® Third -Party <br />INT 3RNATIONAL CODE COUNCIL (',%R'rJV1CA11ON N0,: 6322644 -UC HXPI ?A710N DATB, 11/17/2009 <br />ALTERNATE a DRSiGNATED UST OPERATOR FOR TATS FACILITY toodomaD <br />DESIGNATED OPERA'1'r)R NAME: M Ichaiel (Mike) Lawrence <br />RLLATION TO UST FACILITY (Chae4 ow <br />❑ Owner ❑ Operator ❑ Bmployee <br />® Sm ice Technician ❑ ThirdParty <br />K)SINESS NAME {.t1'dlp'o from aboy0; Tank-T9k Environmenul Corps <br />DESIGNATED OPERATOR MONE: (707) 446-6161 ext. <br />iNTERNATIONAL CODE COUNCIL CMTIPICA71ON NO.: 104$903 -UC <br />EXPIRATION DATE; 1011212009 <br />ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILY1"><' (4p4onao <br />DESIGNATED OPERATOR NAME; <br />RELATION TO UST FACILITY (0mck One) <br />❑ Owner El Operator ❑ Employee <br />❑ Se -vice Technician ❑ This -Party <br />13USB ESS NAME (tOffemef►om above): <br />DBSICINA'rF1) OPEtZA OR PI IONS: eX, <br />INTERNATIONAL CODE COUNCII. Chk-nr'ICATION NO.. <br />WIRATION DATE: <br />A LTERNATZ 3 DESIGNATED UST OPERATOR FOR THIS FACILrry (Ogtionao <br />DESiONAM OPERATOR NAME: <br />ItHI.A110N TO UST FACILITY (Cheek Ona) <br />❑ Ow= ❑ OptAtor [j F,ntpldyee <br />❑ Servlet technician ❑ Third -Party <br />9USIN08NV4 (If d(ifw 11mm abow); <br />DESiGNATED OPERATOR PHONE; <br />INTERNATIONAL COD& COUNCIL CERTIFICN)ION NO.: <br />LXPIRATION DATE; <br />I certify that, for the Facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br />Operator(s). The ludlvldual(s) will conduct and document monthly facility Inspections And annual facility employee training <br />In accordance with California Code of Regulatione, Title ?,3, Section 27)5(c) through (,1). Furthermore, I understand and am <br />In compliance with the regWroments (statuthg, regultlN=4 and local ordinances) applicable to underground storage tanks. <br />TANX OWNER NAME: C%hur Ci• V0 7t�"J <br />TANK OWNER TITLE: Marqq&4mDdqrAa k W L7 t OWNER PRONE; <br />"TANK OWNER SIGNA1'U1i13 DATE; 2 Q %1�7 <br />tHSi�t>�,T� IT QNS <br />1. Report the name(s) of the Dcaignated UST Upomior(s) as regioured with the international Code Council (ICC). ICC certi0cation <br />information is available on-line at: www3makorg/n/eertseareh.htmi. Search for "Calil'bmis UST System Operators;' <br />2. Submit this completed form to the local agency that regulates this faoillty's USTs. Unidocs member agency jurisdictions and <br />contact information am listed on-Une at: www.unidoaorg/members/wboregulmtmwligtthtml, Contact information for other <br />local agencies within Califtnift is available at: www.Nvvreb.ea.gov/cwphome/ust/cont2eb/doeMocal—agencyjilt,xis. <br />3. 23 CCR. §2713(x) requhes that you notify the local agency of any changes to this information within 30 days of the date of change. <br />UN -062 -1/1 www.uoidocs org 09/22/04 <br />