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San Joaquin County <br />Environmental Health Department RECEIVED <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 JUL 11 2013 <br />Owner Statements of Designated Underground Storage Tank (U <br />L H DEQ �1vlEl�i <br />and Understanding of and Compliance with UST Requiremen s <br />Designated UST ORerator(s) for this Facility <br />rfulv1AK I <br />Designated Operator's Name: John Bertao <br />Facility Name: DSS Company <br />Facility ID #: FA0003699 <br />Designated Operator's Phone #: 209-948-0302 <br />International Code Council Certification #: 8 0 0 0 9 5 4 - UC <br />Facility Address: <br />655 W. Clay Street <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />X7 Update Certificate Expiration Date <br />Facility Phone #: 209-948-0302 <br />Designated UST ORerator(s) for this Facility <br />rfulv1AK I <br />Designated Operator's Name: John Bertao <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator X Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 209-948-0302 <br />International Code Council Certification #: 8 0 0 0 9 5 4 - UC <br />Expiration Date: 11 / 18 / 13 <br />ALIEMNAIL' 1 V Itu"U <br />Designated Operator's Name: Steve Az evedo <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator 01 Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: 2 0 9- 9 4 8- 0 3 0 2 <br />International Code Council Certification #: 8000953 -UC <br />Expiration Date: 11 / 18 / 13 <br />LTERNATE 2 1f).tions[) <br />ti <br />Designated Operator's Name: See attached for 3 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician ❑ Third -Party <br />Business Name (If differentfrom above): service technicians. <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 <br />SIGNATURE OF TANK OWNER: <br />DATE: 7/11/13 <br />OWNER'SPHONE#: 209-948-0302 <br />