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San Joaquin County <br /> Ovironmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <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:C 1 T K o±_5:tAr_MrvtJ A Facility ID#: z�A 000 <br /> —facility Address: Reason for Submitting this Form(Check One) <br /> I L4 6.5 -5 L�ej colkk s-f- 0 Change of Designated Operator <br /> Facility Phone#: "7 - -744 1 f7 [3 Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated operator's Name: `-f � Relation to UST Facility(Check One) <br /> (-1tj4]&5 I <br /> Business Name(If differentfrom abot 0 Owner 0 Operator &'Imployee <br /> Designated Operator's Phone#: cj37 - 74 Iq 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:�2 Ll to ILI -(Ae Expiration Date: <br /> _3 ------------- <br /> AILTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check Otte) <br /> Business Name(If differentfront above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Counc*il Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Dcsignatcd.Operator's Name: Relation to UST Facility(Check Otte) <br /> Business Name(If differentfront above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: [3 Service Technician 0 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) -(0. <br /> Furthermore, I understand and am in compliance with the requirements (statutes, <br /> regulations; and local ordinances) applicable to underground st age tanks. ll <br /> NAME OF TANK OWNER(Please Prin L '-'A i j Ri ME or C 1 df S-10 c, <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2, (4 -Oz:) OWNER'S PHONE#: 93-7 - -741 ] <br /> November 2004 <br />