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6 San Joaquin County 0 <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: 4-S ®t :4 2 <br />Facility ID #: <br />Facility Address: C-;� 3 D -,"4-C,� <br />Q.U. C.A ej 3 3 6 <br />Reason for Submitting this Form (Check One) <br />Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 0 � <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Business Name (If different from above): <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator [h' Employee <br />❑ Service Technician ❑ Third -Party <br />Designated Operator's Phone #: SQ 1_47 1 <br />International Code Council Certification #: <br />®® 2 <br />Expiration Date: 12iDD <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <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 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): al JK <br />SIGNATURE OF TANK OWNER: M__=19=WMV41jrWV �IWOWMM�kw��� <br />lig_TV <br />OIN* <br />November 2004 <br />