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1 <br />03/17/2002 20:19 18007697413 PAGE 01 <br />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: 7 -* AI <br />Facility ID <br />Facility Address: <br />F%9WC14, <br />Reason for Submitting this Fohn (Check One) <br />0 Change of Designated Operator <br />0 Update Certificate Expiration Date <br />Facility Phone 0: 209-1 <br />Designated UST 0j2eratoj:(s)for this Facill <br />PRIMARY <br />Designated Operator's Name: . <br />Relation to UST Facility (Check One) <br />Ow-ftr ><Operator 0 Employee <br />0 service Technician 0 Third -Party <br />Expiration Date; <br />Business Name (ffdifferentfrom abo%ye)! g&"5 O;e, <br />_.0 <br />Designated Operator's Phone #:l e -3-7/—;_'57Q <br />q( <br />International Code Council Certification ft; <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 -Owner 13 Operator Cl Employee <br />0 Service Technician 0 Third -Party <br />Business Name (lfdiffercntfroin above).- <br />Designated Operator's 111ionc i-,: <br />International Code Council Certirication 0; <br />Expiration Date: <br />AIJERNATE 2 (Optional) <br />Designated Opomtor's Name-. <br />Relation to us'r Facility (Check <br />0 Owner 0 Operator 12 Employee <br />0 Service Technician bThird-Party <br />Business Name (1fdtflerenifiront.above): <br />Designated Operator's Phonc 4: <br />C, <br />International Code Council Certification <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE C%46NGE. <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 ind1vidual(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) - (0, <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 <br />. I SIGNATURE OF TANK OWNER: <br />DATE- 1240 - 6y OWNER'S PHONE 0: <br />T <br />f2t mo5 0')L -FooV OVIFte- 'of" <br />November 2004 <br />