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,FROM (THU)DEC 30 2004 14:12/ST.14:10/No.6818865743 P 3 <br />t <br />.san .l'oaquill County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Telephone (209) 463•-3420 rax (209) 468-3433 <br />Owner Statements of Desigmted 1.)ncici-gi-oi.ltld Stol-a.ge '.l Erik (CAST) Operator <br />and U`ndc.€,statldint> of and Compliance Wit11 l: 'f Ttr�r�€tirt nactxts <br />........................ .... ....... <br />. ........ _.............__ _ _ _-- _ _- ........ --.. __...._.......:......__.. _- . __.__ �__........... <br />Facility Name_ Valle�t Pacific Petroleum Services, Inc. Faci€ity ID d; FA0_003976 _ <br />Facitity Addrew Reason for Submitting this Fortn (Check One) <br />1501 W. Charter Way, Stockton, CA 95206 __�-- Changeot'Dcsignatcd Operator <br />Facility Phone i': 0 Update Certi icatc Expiration Date <br />Designated UST Operator(s) for this Facilit <br />PRIMARY <br />......................... .................... -------------- -----.......,_ _,_.._..........._.._..v..__.,........,,_. _._.._.� - --- —�_ <br />Desil ilate(I opem or's Mike Eliason -- Relation to UST facility (Cbrck <br />_,..-- ---- _ .............. <br />Jbsincss Nmrc (!f dyfereur fron, 0b. e) valley Pacific Petroleum Svcs, incA D owner n Ulrc:rator F:mpl)}rc <br />Designaied Upe,ator's €'€tone it: (209) 993-8793 i 0 Service Technician t, 'third-Party <br />..W.,,_.�,.,_....._....._....... --- - —_—_ .......-- ___.. . _ __.-�._...................._._._._t <br />International Code Council Certification'5(X4141014087 xptration tate: <br />.........w ............................. _ _ — _ ._ . ....1 <br />ALTERNATE t f0ptiortnl) _ _ <br />— <br />-Dosign3ted Opertator's Namt'Robed Robertson <br />•_•..,..,-.,�.,_.._.__.................. ..... .._ <br />Rclntirm to € €'rl' Fari'ity (Chrek One) <br />I <br />Business Name. (Ifdi£%i is ru fi'<�rn abovNIalle Pacific Petroleum SVCS, Inc. L1 Otvncr n Operator t:mp€o J°cc <br />Desik,nated Olxrator's Phone i1:209 38996 U service'rechnician D '€ hit,I-Party <br />S L27-_ ...._._.._............_ .... _ . M_.__.----�---- _: -..... _ <br />= tnternationai Codc Council Cefialcation 11 l�KOOOt.........................._............_........_. Expiration €Date: <br />---. _... ---—._..........._........._..................... ---- __ ..........__ ..._.. _._._._._.................._ <br />AUITRNATE 2 (Qptiot+al) <br />.,........._............................... ..... _...... <br />._ ... .. _.... _— _ ...._........_. _ I <br />Designated 004,ator'a lanae: Relation to UST facility (CK•rk <br />......_...... .............. . ... ......_................ -...- ---- ----- .. <br />Business Name (!f (lf, ervat turn etbore): <br />r% 1 ...... <br />C] Owner L1 operator i:1 I'srnp€oye� <br />Designated OpQrator's Phone It: 0 Scrvice Technician Q l hind -Party <br />.................................... <br />International Cody C.ouocii Ccrti€kation It: Expiration Date: <br />_.......... ._... <br />_ <br />NO'CE: 'I'IIF, LOC'Ai, REGULA'T'ORY A(:I<,tNCY NITIS'C BE Nul'IFIED OF ANY CHANGES TO "ITIS <br />I fl:()tbt'�TA'I'IOA'4 S3'I'1'JIIN 30 DAYS OA''t'HE CHANGE. <br />i reiitify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />scree as Nsignaced UST Operator(s). The individuals) will conduct and docilnient monthly <br />facility inspections 1i>d annual facility Cl1iployee training, in accordance with California Code of <br />Re,pulatlons, title 23, section 271.5(c) - (f). <br />Furtberniore, I miderstand and ani in compliance with the recfuirelnepts (statute;, <br />rct ulations, and local ordinances) applicable to undcrground storage tanks. <br />NAME' 01PTANK OWNER (I'€ansa I'riet#): tJUrrn C m � -- <br />llA'1't� 12/29!200.1 <br />OWNIstt'S PlIONE#: (209)948-9412 ...... <br />VPPS Charter Way.max <br />Novemb4Dr 2009 <br />