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DEC -13-2006 14:03 FROM:CHOL/MFT 209 476 3096 T0: 94683433 P.2/2 <br />Sin 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 cif and Compliance 'with UST Requirements <br />Facility Namc:- <br />I`''Ll4 1 Facility 117 <br />Facility Address: -7.Y 79 Reason for Submitting; this Fon-n (Clieck 0,,e) <br />J' TCoC.J'�Tr Cil . 15z1® fd" Change ofDesigrtnted Operator <br />Facility Phone .H° <br />(! _ 3 O Update Certificate Expiration Date <br />Designated UST Qperator(s) for this Facility <br />PIUMARY <br />Designated Operator's Name:CAMCA7_AA)ZA&jLfRelation to UST FFacil.ity (Check One) <br />Business Name (Ifdiferenr f,•p,n above): O Owner Ii;! Operator t� Employee <br />Dcsignatcd Operator's Phone ll: �9 .- 7.d SC(QS O Service Technician ❑ Thiid-Party <br />International Codc Council Ceilificalion #: XX'4-�! 022 7 �S Expiration pate: ,�{fd,v �,¢ r►n <br />A!L•PF:RNA TE 1 (Opriorral) w _ -- <br />Ucsignatcd Operator's Namc : <br />Business Name.(lfdjffcrenrfrom above): <br />Designated Operalor's (hone ll: <br />- International Code Council Certification M <br />ALTERNATE 2 (Oprior,a/) <br />Dcsignptcd Operator's Nansc: <br />Business Ntmic (!f different f,-onr above) <br />Designated Operltur's Photic il: <br />Relation to UST Facility (Check One) <br />❑ Owner O Operator O Employee <br />® -SciviccTechnicion O Third-Pa,ty <br />Expiration Date: <br />Relation to US"r Facility (Cheek Ouse) <br />* Owner 0 Operator O Employee <br />O Service Technician O Third -Party <br />lnteinational Code Council Ccrtitication 1h. - - — Fxpiration Date: <br />NOTE, TIM LOCAL REGULATORY AGENCY titCIS'1" ztE N01 VIED OF ANY CHANGES'TO TH(s <br />INFORMATION 'MT1T1N 30 DAYS OF TH117 CHA,IGE. <br />l certify that, fbr the facility indicated at the -top of this..page, the.individual(s) listed -above will <br />serve as Dosignated UST Operator(s). Thc-indzvidual(s) will conduct &Fd:' oGuirient nmonffiffiy <br />facility inspections artd annual facility employee training, in accordance with California Code of <br />1'Reguiations, title 23, section 2715(e) - (f). <br />Furthermore, I understand and ain in compliance %vith the requirement's (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />I"loll <br />SIGIN) <br />)' 3 DATE <br />Nc)vembet 2004 <br />