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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 /> Facility Name: '114 .e T p S T-c D A-L- Facility ID#: <br /> Facility Address: 5 -7-7-7 -T P«'y C-6 (Ct"4P 1Z C? Reason for Submitting this Form(Check One) <br /> Sa t, « 95 a e(o ❑ Change of Designated Operator <br /> Facility Phone#:'ZC)j —qRS_ t.t 7 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:--A\ -&GADbn c-!i Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): CV ,rte AC0ti,,,A ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: C* _ _ 6 ❑ Service Technician 1�—Third-Party <br /> International Code Council Certification#: 0 L4 8q Expiration Date: <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If di,fJerent 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 different 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 /> 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): <br /> SIGNATURE OF TANK OWNER: S�� >f/p•<�r� <br /> DATE: _ I l I OWNER'S PHONE#: 'a13- L(L[�) <br /> November 2004 <br />