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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:San Joaquin RTD Facility ID#: FA0003749 <br /> Facility Address: 1533 east Lindsay Stockton CA 95201 Reason for Submitting this Form(Check One) <br /> X Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Ouerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Douglas Smith Relation to UST Facility(Check One) <br /> Business Name(If different from above):Same ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#:209-993-3728 ❑ Service'Fechnician ❑ Third- <br /> Pang--International Code Council Certification#:8032725-UC Expiration Date: 7/14/2011 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:Mark Farbanks Relation to FIST Facility (Check One) <br /> Business Name(/fdiJfercntfrom above):Same ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#:209-993-3298 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5243795-UC Expiration Date:8/17/2011 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Pam <br /> International Code Council Certification#: Expiration Date: <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): [tn) O <br /> SIGNATURE <br /> EEjOF TANK OWNER: // <br /> DATE: / �Z OWNER'S PHONE#! ULJ�I `f� I <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.povlust/contacts/cupa asys.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />