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San Joaquin County <br /> Environmental Health Department <br /> 304 F.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209)468-3433 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Country Market Cardlock Facility IDA': <br /> Facility Address: 1524 Fresno Ave Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> FacilityPhone o: (209)948-9412 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> a, PRIMARY <br /> 001 <br /> Designated Operators Name:G.Michael Eliason Relation to UST Facility(Check One) <br /> Business Name(lf diereaf from above): Valley Pacific Petroleum Sernsces,Inc ❑ Owner ❑ OperatorEmployee <br /> cv <br /> M Designated Operator's Phone#: (209)948-9412 O Service Technician ❑ Third-Pam- <br /> International Code Council Certification k:U5250416 Expiration Date:1117;06 <br /> z <br /> ALTERNATE I(Optional) <br /> oo <br /> cD Designated Operator's Name: Relation to UST Facility(Check One) <br /> r` <br /> Business Name(If different from above), O Owner O Operator ❑ Employee <br /> cn Designated Operator's Phone#; ❑ Service Technician ❑ Third-Party <br /> cD International Code Council Certification k: Expiration Date: <br /> 0 <br /> r� ALTERNATE 2 (Optional) <br /> Designated Operator`s Name: Relation to UST Facility(Check One) <br /> 0 <br /> N Business Name(If dilferem from above): 13 Owner O Operator ❑ Emplo}ee <br /> a; Designated Operator's Phone#; a Service Technician 11 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 Print):_Mike 'aeon <br /> SIGNATURE OF TANK OWNER: <br /> DATE: �.f Z ���o OWNER'S PHONE#: (Z-5) FYs_-9Y/Z <br /> C] <br /> �Y <br />