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0 0 <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) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: LI- A- Ver et®h <br />Facility ID #: S0003%41 <br />Facility Address: a 15 1 ,G. <br />t*t' ec#,. CA 331, <br />Reason for Submitting this Form (Check One) <br />1< Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: pq- $'3 - 315 <br />Designated UST Operators) for this Facility <br />Designated Operator's Name: & q f .I ().A dw t <br />Relation to UST Facility (Check One) <br />Business Name (Ifdierentfrom above): ❑ Owner ❑ Operator X Employee <br />Designated Operator's Phone #: c7t1 _ $ $- 3 15 ❑ Service Technician ❑ Third -Party <br />International Code Council Certification #: %® 15165 -LA ` Expiration Date -7v- d1_ I I <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Business Name (Ifdierent 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: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent 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 to underground storage tanks. <br />I <br />NAME OF TANK OWNER (Please Print): i <br />SIGNATURE OF TANK OWNER: <br />DATE: -p'A OWNER'S PHONE#: L i <br />November 2004 <br />