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U1, S 1. Pj 2-008 <br />ENViRC)NNIENf HEALTH <br />PER;�!I /SERVICES <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 7789 Quick Stuff <br />Facility ID #: FA0017737 <br />Facility Address: 10858 Trinity Parkway <br />Stockton CA 95219 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />El Update Certificate Expiration Date <br />Facility Phone #: (209) 952-9541 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Joe Notary <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician El Third -Party <br />Business Name Qfdii ferent from above): PCET <br />Designated Operator's Phone #: (760) 421-0040 <br />International Code Council Certification #:8010930 -UC <br />Expiration Date: 5/2/2010 <br />ALTERNATE l (Optional) <br />Designated Operator's Name: Paul Vidakovich <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician El Third -Party <br />Business Name (If different from above): PCET <br />Designated Operator's Phone #: (760) 421-0400 <br />International Code Council Certification #: 8012392 -UC <br />Expiration Date: 6/3/2010 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: John Kirk <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator E3 Employee <br />❑ Service Technician El Third -Party <br />Business Name (If different from above): PCET <br />Designated Operator's Phone #: (760) 889-3115 <br />International Code Council Certification #: 8016990- UC <br />Expiration Date: 8/29/2010 <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 <br />OR OWNER'S AGENT (Please Print): <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />Daniel A. Erickson <br />DATE: 10/9/08 OWNER'S PHONE #: (847) 888-0276 <br />September 2004 <br />