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12/24/2004 10:04 2099510072 STEPHENS-RIVPT LNDG PAGE 02 <br /> �r <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 'rank (USI') Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: �: iwiT Facility ID M <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> Q 5 d LOA1 ❑ Change of Designated Operator <br /> Facility Phone ft:(jbq1 951 Lj iy ❑ Update Certificate Expiration Date <br /> Designated UST Operators for this Facility <br /> PRIMARY <br /> Designated Operator's Nainc: & Relation to VST Facility(Check One) <br /> Busitim Name(If different from above) rV ❑ Owner ❑ Operator Cr Employee <br /> Designated Operator's Phone -Q q PC Z Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: t <br /> ALTERNA'T'E 1 (Optional), <br /> Designated Operator's Name: relation to UST Facility(Check(7ne) <br /> Business Name(If differenl frorrr above): a Owner O Operator ❑ Employee <br /> Designated Operator's Phone#: 0 Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE I (aptional) _ <br /> aesignatcd Operator's Name: Relation to UST Facility(Cluck One) <br /> Business Name(If differentfrom above); 0 Owner 0 Operator C] Employee <br /> Designated Operator's Phone 4: 4 Service Technician ❑ Third-Party <br /> International Codc 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 Califoniia 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): 4e,.,s i <br /> SIGNATURE OF TANK OWNER. <br /> 5S P� s i INC <br /> DATE:/�Azr Aq OWNER'S PHONE#: .269 45'/- 4S19S <br /> November 2004 <br />