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San Joaquin County * P?,EFC <br /> Environmental Health Department el <br /> 304 E. Weber Ave., Third Floor Stockton CA 95202 <br /> Telephone (209) 468-3420 Fax(209) 468-3433 MAY <br /> 2014 eo <br /> Owner Statements of Designated Underground Storage Ta ' ator <br /> and Understanding of and Compliance with UST RequireQOA�T�� HEALTH <br /> Facility Name: Valley Pacific Petroleum Charter Way Cardlock Facility ID#: <br /> Facility Address: 1501 W Charter Way Reason for Submitting this Form(Check One) <br /> Stockton, CA 95206 ❑ Change of Designated Operator <br /> Facility Phone#: 209-948-9412 N Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: G. Michael Ellason Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator [X Employee <br /> Designated Operator's Phone#:559 732-8381 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5250416-UC Expiration Date:4/1/2015 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:,James Abbott Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator 19 Employee <br /> Designated Operator's Phone#:209 601-4641 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 8006067-UC Expiration Date: 5/15/2016 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 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 /> NAME OF TANK OWNER(Please Print): Mike Eliason <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 5/15/2014 OWNER'S PHONE#: 559 732-8381 <br />