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12,10/2004 12:20 FAX 11002 <br />Barr J4"uin County <br />EwAmunental Health Departinent <br />304 •E: Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (204) 468-3420 Fax (209) 468-3433 <br />IRVRPM <br />>~. <br />Facility Name: P eo sZ(p <br />Facility ID if: <br />Faclifily <br />/T"'` �� <br />Reason for SubmiirIng this Form (Gheck One) <br />3 a❑ <br />Change of Dasignatcd Opermw <br />A Update Cerflfkeam 87tpiration Data <br />Facility Phone #: <br />;2esignated U§:[ OtQerator(s) for ibis Facility <br />n®Y1a0e A YDv <br />Dcsicmate d 's Name: <br />Business Name (Ifd(Q"ea"anrfrom above): <br />Relation to UST Facility (Check One) <br />13 Owner ❑ Operator ❑ Employee <br />W Service Technician a Third -Doty <br />Msagnate:d Operator's Phone C /)V-7 .-7 <br />ante mationai Code Council C <br />Expiratioe Date: �l h <br />ALTERNATE t (OpdPI <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />ttasiness Nam (IfdVaren: frons abpve)_ O Owner ❑ Operator ❑ Employee <br />Designated Operators Phone #: 0 Service Technician ❑ TbiN-Party <br />international Code Council Cettificatim N.- Expired= hate: <br />ALTERNATE 2 ( ' earl) <br />Dcsigrwed Uperator's Name: Relation to UST Facility (Check 0w) <br />Business.NDim (ifdWereiztfron, above): ❑ Owner b Operator Cl Employee <br />Designated Operator's ]Phone #: Q Servide Tochnicia n Q Third -Parry <br />tnteinational Code Council Certiftollon #: Expiration Date: <br />� is • . � � . t � , e 1 ' :� t � ; � � / i t <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 candttctanei dne.nment monthly <br />facility ilaspections and annual facility employee trainin& in accordance with California Code of <br />P�egulations, title 23, sections 2715(c) - (£). <br />1 1 1 Y i ' Y. i i.: : I 1 7'. t Y:1: i t 1 1 P -M1 1 i 1-0 jjfL +ti. <br />SIGNATME <br />DATE: <br />,r s <br />L <br />November 2004 <br />E® 3E)Vd N01>1001S dHa 1998—Eb6-6BZ 6ti:1L b0®Z/06/Zl <br />