Laserfiche WebLink
San Joaquin County RECENED <br /> Environmental Health Department a OIQ <br /> 600 E. Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209) 468-3433 ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:,S C- -f/c;S //1- Facility ID#: <br /> Facili Address: Reason for Submitting this Form(Check One) <br /> ty 70��M t GNt>�c.. C,,�-NGS �c..✓0 • t' <br /> .a c C Change of Designated Operator/40,0 4 -IC-aN <br /> Facility Phone#: 6 3,7 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: JF--S-SE5 47 U.'"16A.1 Relation to UST Facility(Check One) <br /> Business Name(If different from above): ( y jpkgCs. ❑/Owner ❑ Operator [I Employee <br /> Designated Operator's Phone# ,V q 3 PQ Cil Service Technician Third-Party <br /> International Code Council Certification#: &0 r —0 Expiration Date: m—&/ �/'D <br /> ALTERNATE 1 (Optional) <br /> j'S �/ Relation to UST Facility(Check One) <br /> Designated Operator's Name: i <br /> Business Name(If different from above).&M64,C e /� ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: eService Technician Third-Party <br /> International Code Council Certification#: .Z _U Expiration Date: 9' /S—,�►® <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 Print):ysj <br /> caN A. FD I-%- SJC, <br /> SIGNATURE OF TANKMO -OWNER'S <br /> PHONE# .�-V�� "" 6 3 DATE: /2-q --�.— <br /> November 2004 <br />