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San Joaquin County <br /> Environmental Health Departme <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 sad G '; ZU04 <br /> Telephone(209)468=3420 Fax (209) 468-3433 <br /> i_i P <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: a641 t/-':- Facility ID#: FA UOU/9' 6 <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> OGk-T, OrV 1 -a (?_f'965>6 a<*'hange of Designated Operator <br /> Facility Phone#:"?e l* 9�L yc�/9 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: K _w PAI Y. <br /> 19 � ) Relation to UST Facility(Check One) <br /> Business Name(If di./ferent from above): l/ &/j 0 �ATPP G O Owner ❑ Operator. ❑ Employee <br /> Designated Operator's Phone#: 2D9 ('v3 lq-(O ❑ Service Technician PK Third-Party <br /> International Code Council Certification#: 5249603—UC Expiration Date: <br /> ALTERNATE I (Optional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International 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): ❑ 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.r <br /> NAME OF TANK OWNER(Ple IIAt : - c7�Z 2 <br /> SIGNATURE OF TANK OWNER: <br /> • DATEA— - /Fd I OWNER'S PHONE#:(Zy 9 <br /> 2— <br /> November 2004 <br />