Laserfiche WebLink
0 0 <br /> 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 /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 1Vw A -"AIA T Facility ID#: <br /> Facility Address: O-(/ 9S2-7 7 Reason for Submitting this Form(Check One) <br /> -/ (/« p Y Locl*Upd C/A ❑ Change of Designated Operator <br /> Facility Phone#: Update Certificate Expiration Date <br /> Designated UST Ooerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: A014)/ Q ULA 0 Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator a4mployee <br /> Designated Operator's Phone#: Service Technician ❑ Third-Party <br /> International Code Council Certification#: SZ 492,0-j - VC, Expiration Date: 3 d si <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: C-"A /✓ Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator V Employee <br /> Designated Operator's Phone#: f4— 3 1(, —,,7 2 Gr/') ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: s2�U 1 6 .U C Expiration Date: /7 lat <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: 1215V t CHI' ,4 L 14'/C- Relation to UST Facility(Check One) <br /> Business Name(Ifdiierent from above): ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: U 'yf Uy <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):: yC ,oG�)di✓�1 G�� <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE <br /> November 2004 <br />