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4' -Sec -31-04 11:48A GEO E KISHIDA INC 209 368 3234 <br />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 />F11 Nantc: f G_.— -------- -- Facility ID r+: S"�ji000 ?75"6 <br />I ocilih Address- <br />2XZx <br />Rc46,e NmeReaw)n for Submitting thy, Forni iCheck Qj 9S-2Pb _ _ V Change ot'Designate i ( rcrat:ir <br />Pacilih A6 <br />Phone_ 249-,9 •06a3- — — — _ ❑ Update Certificate 1:,.pr•.atwn Date._..._ <br />Designated UST QpSrator(s) for this Facility <br />PR1>IARV <br />DesignaW Ope;ratm', Name. G`KrG.� <br />/� .1�/r - <br />Relation to t 1ST Facilih 1 '%a <br />cb ( ae) <br />Husine"-Namc(f/'r!i(7Jrvra/i�mrcibuve) <br />❑ Owner ❑ Opcnncor <br />k!1'I.mp1uyec <br />D, sigruncxl Operator-, Phone '+: �?Qg _36� • <br />f `•� <br />❑ Service Technician ;:: <br />I hind -Park <br />International (ycxtc (';ouncil Certification:': __-- <br />Expiration Date! <br />Dcsignatcd Olu:ratm'. Name: <br />Relation to UST Facility <br />Business Name (If (iffi,rent from above/: <br />0 Owner ❑ Olvrator <br />Finplovice <br />Dcsil;nated Operai r Phune ., <br />❑ Sentcc Technician <br />1 hird-Parte 1 <br />int, nmzw t al Code ( ,kincil Ck�`hficati ait - . <br />�I.�hira9u:n D atc. <br />� <br />ALTERNATE 2 (!lpfional) <br />Designated (llx:ratx's Name: <br />Relation to 1JS'1' Faeihh t+'%r rb One) <br />Business Nanic (If Ol m-pil jremi above/: —�- <br />- <br />❑ Owtter ❑ Operator <br />_: Frnplo� ee <br />Dcsignalul Orwrab,r s fiione :': <br />❑ Service: Technician <br />I bird-l'am <br />International Cexie (';nmcil Certification : <br />Expiration Date: <br />!VOTE: 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 xNill <br />serve as Designated UST Operator(s). The individual(s) wIII conduct and document rnonthh <br />facility inspections and annual facility employee training- in accordance ikith Califamta Code of <br />Regulations, title 23. section 2715(c) - (€). <br />Furthermore, t understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Pleaw Print): (� 04m e <br />SIGNATURE OF TANK OWNER: <br />®/ / <br />DATE: 001 1Jj OWNE.R'SPHIONE#: <br />0 <br />Narxrnther 2(X)4 <br />MON <br />