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Dec .27 . 2004 12:22PM S11TTER TRACY ADMINISTRATION No •3688 P . 2/3 <br /> Satz Joaquin County 0 <br /> Environmental Health Department <br /> 304 L Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)46.5-3420 Fax(209)468-3433 ' <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> . and Understanding of and Compliance with UST ReTaireme-nts <br /> Facility Name: Sa+f el—-rvzec rym ' } f Facility ID#: <br /> Facility Address! /,',20 Aj 'T► j3d vel. Reason for Submitting this Form(Check One) <br /> 7M— . 14 Change of Designated Operator <br /> Facility Phone 0; s ❑ Update Certificate Expiration Date <br /> Desienated UST erator(s)for this Facility <br /> PPIMARY <br /> Designated Operator's Name: Pedro f on-za!e, Relation to UST Facility(Check Ogre) <br /> Business Name(Ifdierentfrom above): ❑ Owner ❑ Operator X Employec <br /> Designated Operator's Phone#: apt 3A ❑ Service Technician ❑ Third-Party <br /> International Codo.Council Certification (fr ?^J" Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name; Relation to UST Facility(Check One) <br /> Business Name(Ifdiererat from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> !nternational 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). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#; ❑ Service Technician ❑ Third-Parry <br /> International Code Council Certification#: Expiration Date; <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHAINGES TO TWS <br /> INFORMATION WITHIN 30 DAYS OF TM CHANGE. <br /> E. <br /> I certify that, for the fdcility indicated at the top of this page, the individual(s)listed above will <br /> serge 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(e) -(f). <br /> Furthermore, I understand and am in.compliaatce with the requirements (statutes, <br /> regulations, and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): R o rd M -- <br /> r <br /> SIGNATURE OF TANK OWNER: y <br /> DATE: l'� 9L-7/.qo 0 OWNER'S PHONE#, C.L-0 d J� 603 <br /> November 2004 <br />