Laserfiche WebLink
San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: • S O Gtr uicL.Facility <br />ID_ #: <br />Facility Address: 1 Li—) F • LAri+pZP <br />C C16 a 34 <br />Reason for Submitting this Form (Check One) <br />O'�'Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: CQ. WPO'e j <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />2—tervice Technician ❑ Third -Party <br />Business Name (If di•,tjerent from above) Pr�c� s r <br />Designated Operator's Phone #:01 IL, <br />International Code Council Certification #: rj L O( — L� <br />Expiration Date: <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name:TFF Qr �js <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />L"Service Technician ❑ Third -Party <br />Business Name (If different from above).•(,,' hu Pi t'.1 Sti a <br />Designated Operator's Phone #: cAti, .-G�2-j _ <br />International Code Council Certification #: NC, lj �;T 24%G' O ►3t- VYINI1 <br />Expiration Date: i t _(L—O(r <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: (pQry F e <br />.;�� <br />Relation to UST Facility (Check One) <br />❑ ,Owner ❑ Operator ❑ Employee <br />51" Service Technician ❑ Third -Party <br />Business Name (If diBerent from above): C Qyv,, 10� tic= <br />Designated Operator's Phone #: _ �� z i ` , -� - <br />International Code Council Certification #: 52- 2— i.ti.. L <br />Expiration Date:l —1L_—o5— <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 <br />SIGNATURE OF TANK OWNER: <br />U <br />DATE: 124 yc;e,14 OWNER'S PHONE #: ZOct -X34i <br />November 2004 <br />