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tj1 i t)ri znt7:) 11:45 LE7y4bti34 i i FIFTH FLOOR PAGE X01 San JoaquinCounty Environmel tal Health Department DEC 2 8 200 304 E.Weber Aver Third Floor Stockton CA 95201 Telephone(209)468-3420 Fax(209)468=3433 �Jt�i::;', .,.:`. :.i •. n: : Owner Statetnents of Designated Underground Storage Tank (UST) Operator and thideI standing-of and Compliance ce with UST Requlrenlents Facility Nautc: FQad 1,1 , Faci);ty.) t.:. Facility Address: Reason forSubmittingthis Forni(Check Oris) CC-. W57-04 19 Change of Designated Operator Facility Phone V:( ,Qq_, (441%— I'lt1 0 Updatc Certificate Expiration Date Desiariated USY0perator((s)for this Facility PRIMARY Designated OPerator.'s Nan:c: _Rob e_•r—t h-�: Lu-4,i, Relation to UST Facility(Check One) fsisinass Native�:,Wooreni front aboKpc 1K Owner 0 operator O Employee Designated Operator's Phone#:c2tn CtS-1—g50C, O Service Technician O Tlird-Pany International Codc.Council Certification P:_I„_uV,000 t,,/r.249 54 1-Uc Expiration.Date: m/2.Vo.ta. ALTERNATE t j0 Tonal Designated Operator's Name: Relation to UST Facility(Check Orae) Business Name(if d&rend fron(above): Q Owner ❑ Operator ❑ Employee Dcsip» ted Optvator's Phone lt: D Service Technician ❑ nird-Party International Codi:-Council Ccairication it: Expiration Date: AVffERNATE 2 (0priohat) Dcsignatcd Operator's N.une. Relation to OST Facility(Check One) Business Name(If differeaffivin above): 0 Owner O Operator ❑ Employee Dcsignascd_Oiau:ataa'.s.l'hane.il: O Service.Tcchnician p Third-Party International Code Council Certification fl: Expiration Date: NOXI:"1:HE LOCAL REGULAT(}RY AGENCY i1•IU87"BE NOTI)nIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. I certify that, for the facility indicated at the top of this page,the indiuidual(s)listed above will serve as Designated UST Operwor(s). The individual(s)will conduct and.docurnent monthly facility inspections and arurttal facility employee training,in accordance with California'Code of Regulations,title 23,section 2715(c)-(f). Furthermore,1 understand and am iu compliance with the requirements(statutes, regulations,and local ordinances) applicable to underground-storage taults. NAME OF TANK ONVNER(Please PAW): 5?r eY'A f � SIGNATURE OF TANK OVVNI,R: X71�-✓ ►�' �� DATE: Ml2�t/oy _.OWNER'S P140NE#.- ..(2.0%') q5'l—°150 5 Novcrribcr 2004