Laserfiche WebLink
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 /> FacilityName: Facility ID#: <br /> Facility Address: A°137 N. W i l—,a e1 Reason for Submitting this Form(Check One) <br /> ts 7-,Oak Q % X Change of D ter D vim <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Al" Q h h '-®' Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): j9 p oL61® V,'9 df a PeTrai-ijvlo Owner ❑ operator ❑ Employee <br /> Designated Operator's Phone#: q 2 6 ,- 3,aq_ ❑ Service Technician Third-Party <br /> International Code Council Certification#: 15 2 Expiration Date: 10 _-I'�f—C> <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 Print): � �-► r1 t4,-4k OW 14 o; <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12 III <br /> ®S OWNER'S PHONE#: <br /> November 2004 <br />