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r San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., 'Third Floor Stockton CA 95202 <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />FQVE C <br />DEC 2 3 2004 <br />ENVfRQA)E:I'l i rig!' I_ 1 r, <br />PERM IIiSF-r;�.r r f <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name:p }< 1t � - l �� ; <br />Facility ID #:cc <br />Facility Address: & Pe 33 LX,-Cj1") U I t e_ifi I r- , <br />t4Zl-_(") I I o',- Cf 5 2-15 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 2-001 ' 9 43 +-0l.1 3 <br />Designated UST Operator s() for this Facility <br />PRIITARY <br />Designated Operator's Name: }t 1(� j` f YY ( iL1 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator C14mployce <br />❑ Service Technician ❑ Third -Party <br />Business Name (1ffclifferent front above): _m <br />Designated Operator's Phone #: 1 Cwt __C'i� Z` " <br />International Code Council Certification #: j ! LA ILI ( 3rj Li <br />Expiration Date: <br />ALTERNATE t (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifclifferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE Z (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check Otte) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different front above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />NOTE: THE LOCAL REGULATORY AGENCY MUST DE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated a, 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 OWNI <br />SIGNATURE OF TANI{ <br />DATE: 11`k 4A " 1 OWNER'S PHONE #: [ L4 '` j)CG' L«,(_ t-, <br />November 2004 <br />