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/' <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA� 2 <br /> Telephone (209) 468-3420 Fax(209) 468-34 OCT 25 <br /> S <br /> Owner Statements of Designated Underground Storage �L'� iej <br /> Irt�>� <br /> TAL <br /> and Understanding of and Compliance with UST ReqrtlEN r <br /> Facility Name:-'VtW Q GUHS r(5)001 (EL- Facility ID#: N _ ssct <br /> Facility Address: Cj C, _ Reason for Submitting this Form(Check One) <br /> L/ 1• VChange of Designated Operator <br /> Facility Phone#: Zoel - ; (� ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Grg!a or CA.7-1' Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator W<Mployee <br /> Designated Operator's Phone#: L�q- 8518 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: �"' L f J •-L!G Expiration Date: <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: 6!#u c k- Relation to UST Facility(Check One) <br /> Business Name(If different from above): C,P. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: �/ 3 i f 3 - -7ao 1 ❑ Service Technician �hird-Party <br /> International Code Council Certification#: 6:9 SID,;?5-1- Ute Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: E C)7 ERelation to UST Facility(Check One) . <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Li'•Z_ U ❑ Service Techniciang, iird-Party <br /> International Code Council Certification#:G ...3 Y 3Expiration 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 : 64 WA- CINVU0�S <br /> SIGNATURE OF TANK OWNER: <br /> DATE: /�c�-�`© OWNER'S PHONE#: -00q--2 3q - /y/y <br /> November 2004 <br />