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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 <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#: FAO 0 0 3 6 9 9 <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 655 W. Clay Street, Stockton, CA <br /> A!I Change of Designated Operator <br /> Facility Phone#: 209-948-0302 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: John Bertao Relation to UST Facility(Check One) <br /> Business Name Qf different from above): ❑ Owner ❑ Operator X 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: 11/2 9/0 9 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Steve Az evedo Relation to UST Facility(Check One) <br /> Business Name(If dierent 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#: 8000953-UC Expiration Date:11/29/09 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: See attached for 3 Relation to UST Facility(Check One) <br /> Business Name Qfdriferentfromabove): service technicians. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: X 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): Stev ssoyan - President DSS Company <br /> SIGNATURE OF TANK OWNER: <br /> DATE: /e/.or OWNER'S PHONE#: 209-948-0302 <br /> November 2004 <br />