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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 f <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: DSS Company Facility ID#: FA0003699 <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 655 W.Clay Street <br /> ❑ Change of Designated Operator <br /> Facility Phone#: 209-948-0302 IX Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: John Bertao Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator K Employee <br /> Designated Operator's Phone#: 209-948-0302 ❑ Service Technician ❑ Third-Party. <br /> International Code Council Certification#: 8 0 0 0 9 5 4-UC Expiration Date:11-18-15 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Steve Piz evedo Relation to UST Facility(Check One) <br /> Business Name(1f dfferent from above): ❑ Owner ❑ Operator IX Employee <br /> Designated Operator's Phone#: 2 0 9-9 4 8-0 3 0 2 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8 0 0 0 9 5 3-UC Expiration Date: 11-7-15 <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): DSS Com an <br /> SIGNATURE OF TANK OWNER: <br /> Qb <br /> DATE: 6/18/14 OWNER'S PHONE#: 209-948-0302 <br /> November 2004 <br />