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10/03/2007 09:38 #0050 P.003 /021 Sau Joaquin County Environmental Health Department 600 E. Main Street Stockton CA 95202 Telephone (209) 468-3420 Fax (209) 46"33 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Narerc: Facility ID #: Facility Address: Rcason for Submitting this Form (Check One) ❑ Change of Designatod operator ❑ Update Certificate Expiration Date Facility Phone #: Designated UST UUerator(3) for this F ITTITTIM Dcsignawd Operatoes Name: Relation to UST Facility (Check One) ❑ Owner ❑ operator ❑ EmpIoyee ❑ service Technician ❑ Third -Party Bumncss Name (Lfdifferent from above): Designated operator's Phone #: Intcrnational Codc Council Certification #: Expiration Date: ALTERNATE 1 (UFdoaal) DesignaWl Opcmtor's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operaw O Employee ❑ Service Technician ❑ Third -Party Business Name (If&fferent from ahave): Designated Operator's phone #: International Code Council Certification #: Expiration Date: ALTERNATE 2 (opdoeaad) Designated Oper atoet, Name: Relation to LIST Facility (Check Orae) ❑ Owner ❑ Operator ❑ Employc o ❑ Service Technician ❑ Third -Party PAisiness Naane (Ifdifferent from above): Dcsignatcd Operator's Phone #: Intettrational Code Council Certification #: Expiration Date: r : r a rt t cit ► r,IIII • t sV COJCWAJtr I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am is compliance with the requirements (statutes, regulatious, and local ordinances) applicable to underground storage tanks.. SIGNATURE OF s 04' 1 1 D!'r#1011 -