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s <br />4 <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main Street Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />Owner Statements of Designated Underground Storage Tank (UST) <br />and Understanding of and Compliance with UST Requirements <br />JAN <br />Facility Name: dile OP M l9 )L C r Facility ID 0006 <br />Facility Address:t �- Reason for Submitting this Form (Check One) <br />L m �" / �� �- ❑ Change of Designated Operator <br />Facility Phone #: 0 _ o) 3 - `tel G Update Certificate Expiration Date <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: 14 G` Agg ff l Relation to UST Facility (Check One) <br />Business Name (If different from above): /10)2-C1�-L7147 M 5fM26 Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: 2 — 3 ?5 - ) 2 /2 /+ ❑ Service Technician X Third -Party <br />International Code Council Certification #: 15 Z L13 P! 7 _ t/ C, Expiration Date: Q — 3 — 2O/ <br />♦ i TT"XT A TL' 1 //1..1'....../1 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />Ar'r RNATF 7 /0nli-11 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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 touilderground storage tanks. <br />NAME OF TANK OWNER (Please Print): 81--tpl /A,4m ao') <br />SIGNATURE OF TANK OWNER: 1/'00V A4 l i► Cd • 2 <br />DATE: �� �.S OWNER'S PHONE #: (�d f a3^ <br />November 2004 <br />