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04/18/2013 11:51 2093344684 05032 P.017 /020 <br /> san Joaquin county <br /> Euvironmentalflealth Department <br /> 600 E. in Street Stockton CA 95M <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: s^ Facility ID#- <br /> Facility Addrew- <br /> Remon for Subauttizig this Form(Check Om) <br /> Al 71 lV, 0 Chanp of Dosignated Opomtar <br /> Facft Phone,#. <br /> 0 Update Certificate <br /> Expiration Date <br /> Desi ted UST QRgMLodsj for this nghft <br /> PRD"RY <br /> Dedpated Operator's Name: Relation to UST Facility <br /> (Check One) <br /> Business Name(YdtFere?Mfr=above):)V 0 OwiiCT 0 Operator 0 Einplo)mc <br /> TAWguatcd Opersor's Phone oe Sel-10C TOdmidaft Q Third-Petty <br /> blernalimW Cvdc Council Certification Eviration Datm. <br /> ALTERNAT'E ILomen-wj <br /> Desigwed Operdoes Name. Relation to UST FwWW(Check On) <br /> Businea Nmc(ffaffewntfrom above): Q Owner 0 Opmator 13 Employee, <br /> LNsigmeed Operatoes Phone 4, C3 Service Technician 0 Turd-party <br /> InternationW Cak Council Certification# Expiradw Date: <br /> AL ATF 2 (OpdomV <br /> DesigaftW OperaWs Name. Relation to UST Facility(Chft*one) <br /> Bminm Nme @'differeXfrom above): 0 Owner Q OPOW-or ® Employee <br /> Dedguated OperAwes Phow 13 Sm im Technician 0 Third-Party <br /> inurnanonal <br /> Code Council Certification 9: Eviration Date; <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFO RMAnON V47RM 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 load ordinances)applica, to underground storage tanks. <br /> NAME OF TANK OWNER(Pkue Print)- r—ce <br /> SIGNATURE OFT OWNER: <br /> DATE. • OWNER'S PHONE fi: <br /> November 2004 <br />