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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) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName: ML—l-, A.V. VG(e'L®ds Facility ID#: FA (7 a7 <br /> Facility Address: 13SSo fJ. o e V f i ty v Y Reason for Submitting this Form(Check One) <br /> O a i i (-A 151L1,7 X Change of Designated Operator <br /> Facility Phone#: a pGl- 115_I 151-A ❑ Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: &q ur y u►vA t® Rela'ion to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator P Employee <br /> Designated Operator's Phone#: a cpfi- %Is- -315 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: t® S)-s_w. Expiration Date: <br /> ALTERNATE 1 donal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent 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(Ifdii ferentfrom 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): 4f r. J <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 09OWNER'S PHONE#: {�4- J`�' <br /> November 2004 <br />