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4M <br /> 16 0 <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:655 W.Clay St.Stockton,CA 95206 Reason for Submitting this Form(Check One) <br /> YChange of Designated Operator <br /> Facility Phone#:209-948-0302 0 Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> P <br /> Designated Operator's Name:Dennis Hunter Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator &"Employee <br /> Designated Operator's Phone#:209-948-0302 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:5242508-UC Expiration Date:09/14/06 <br /> ALTERNATE 1(Qoonal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> hitemational 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): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <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): <br /> SIGNATURE OF TANK OWNER!.'-­­­ <br /> STZ�VE, ESSO 0 <br /> DATE: OWNER'S Pr NE—#---' 209-948-0302 <br /> ------------ <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO TH` ALAG"Y (NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.Rov/ust/contacts/cui)a ajzvs.htmL <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />