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- <br /> San Joaquin County <br /> Environmental health Department <br /> e 2 2 <br /> 304 E. Weber Ave.,Third Floor Stockton 468-3433 CA 95202 <br /> Telephone 468-3420 Fax09 DEC <br /> C 2, 2004 <br /> Owner Statements of Designated Underground Storage 'Tank (US:T),Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: OILS Facility ID#: 2 <br /> Facility Address: ILJ26 w .I *37jA4 Reason.for Submitting this Form(Check One) <br /> �^0 Ai El"'Change of Designated Operator <br /> Facility Phone#:_2 • VW0 ❑ Update Certificate Expiration Date <br /> Designated UST Oyerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: II Relation to UST Facility(Check One) <br /> Business Name Qf different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 2 31 ❑ Service Technician Third-Party <br /> International Code Council Certification#: q 11 C Expiration Date: 10 / 046 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Indifferent frons 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 r•om 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. <br /> NAME OF TANK OWNER(Please Print):e --' Y` <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 1 OWNER'S PHONE#: G 7 Z3 <br /> November 2004 <br />