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San Joaquin County <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) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: _ _ Facility ID#: <br /> Facility Address: Z` �J Ac'._vv�,w.&r- Reason for Submitting this Form(Check One) <br /> !C ❑ Change of Designated Operator <br /> Facility Phone#: �_C (32-5 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: _ z Relation to UST Facility(Check One) <br /> Business Name(If different from above): _ _ .- W Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: l ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 'S 4 !2 a Uj� Expiration Date: J <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 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 Printf: <br /> j r _ <br /> SIGNATURE OF TANK OWNER: <br /> DATE: f <br /> ,,Z:Z //7 OWNER'S PHONE#: <br />