Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street 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 /> FacilityName: FacilityID#: <br /> Facility Address:5--7-7-7S F,-.1-C14 C-;:Y--P 2 Reason for Submitting this Form(Check One) <br /> S,1V cc- o,, 9sa o 6 ❑ Change of Designated Operator <br /> Facility Phone#: 'Z _ ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: e,iL A cA (A Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): gotCCJL RA t w1 ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ) _3 g _ 2 L,2— ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:Sa L Expiration Date: <br /> ALTERNATE 1 (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-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 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 /> 1 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): <br /> 1� <br /> SIGNATURE OF TANK OWNER: <br /> DATE: I "O V OWNER'S PHONE#: <br /> November 2004 <br />