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FEB -26-2002 07:35A FROM: T 013 P:2/3 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave.,'Fbird Floor Stockton CA 95202 <br />'Felephone (209) 468-3420 Fax (209) 468®3433 <br />Owner Statements of Designated Under,,,7,ound Storage Tank (UST) Operator <br />and Understanding of and Conipli-ance with'OST Requirements <br />Facility Nary 6g 5 Fucility ID #; <br />FA 000 X I -Q <br />Facility Addrcss: qt #d P, F7r_M O'n i> Reason for Submitting this Form (Check One) <br />5 hvjr?&,,j 4CA 9.5 2 D Changc of Designated Operator <br />Facility Phunu It; o Update Certificate Expiration Date <br />Desimiated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: 6jre. w&j Relation to UST Facility (Check (bye) <br />Business Namc (lidjirenifi-om above): Owner 0 Operatur 0 Employee <br />Dasignawd Operator's Phoric fi: ihf_ 16 olyd 0 SefviceTechniciun 0 Third -Party <br />International Code Council Certification. 9: y Expiration Date. - <br />ALTERNATE 1, (0 <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Business Name (lfdifferenljtonz fzbove.).- <br />0 Owner 0 Operator 11 Employee <br />Designated Operator's Phone A. 0 Scryicc Technician 0 Third -Party <br />Inteinafional Code Council Certification #: Expiration Date: <br />,ZINERNATE2 <br />Designated Operator'-, NAMC; Relation to UST Facility ((,hock One) <br />Business Name (Y'd!).Tcrentfront above). -Third n owner 0 Operator C1 Fmploycc <br />)cSi.11 le . a Operator's Phunc 0 Scrvicc Technician L -3 -Party <br />International Code Council Certification Expiration Date: <br />NOTE: THE LOCAL REGAILATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN .30I)AYS OF TkIE 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 LIST 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 tarjU. <br />NAME OF TANK OWNER (Please <br />SIGNATURt OF TANK OWNER,: <br />DATE: OWNER'S PHONE N - <br />November 2004 <br />