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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 /> Facility Name: P11%U-1. Facility 1D#: FA 0014-57) <br /> Facility Address: 0-551 F-. L '.1C AV<. Reason for Submitting this Form(Check One) <br /> ea n C E�, (-A ot 53 g 11 Change of Designated Operator <br /> Facility Phone#: �1_ 1,344 0 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: E f Relation to UST Facility(Check One) <br /> Business Name(If diffierentfrom above): PIN4a 0 Owner 0 Operator XEmployee <br /> Designated Operator's Phone#: -A 15 - U43 1161�0161 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: lae-,e Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/ differentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 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(Ifdifferent from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 11 Service Technician 0 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 incompliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Half, N <br /> SIGNATURE OF TANK OWNER: <br /> C� <br /> DATE: OWNER'S PHONE ft: <br /> November 2004 <br />