Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department , <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 DEC 2 1 2004 <br /> Telephone (209) 468-3420 Fax(209)468-3433 <br /> ENV; , ; <br /> �)ER1111Iis �.�' �J16,-b <br /> OwnerStatementsof Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name- % Z 6. dL 'A 600 <br /> Facility ID#: <br /> Facility Acd,dress: Reason for Submitting this Form(Check One) <br /> 114 b e1 , Ai co Rr"Change of Designated Operator <br /> Facility Phone -Z --7 /7 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> ---- ---------------- t <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator Employee <br /> Designated Operator's Phone# CI 3-7®�Z k4 17 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 (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 /> 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 Printf. AT Z 6 9 0 i a L 't <br /> SIGNATURE OF TANK OWNER: e eI d <br /> DATE: - / _ OWNER'S PHONE# ! !237-7Y/? <br /> November 2004 <br />