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�.. - RECEIVE® <br /> San Joaquin County <br /> Environmental Health Department ,,;A 2 9 <br /> 600 E.Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209)468-3433 ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: G,, • TAowd#00vwmP.) YAX�c Facility ID#: <br /> FacilityAddress: 1 47S w• t..At.s Lr+/.. A4190m C Reason for Submitting this Form(Check One) <br /> T p pr✓y CA g S 3 7 6 Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Desi¢nated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 34asv 9FAUm$t-) Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician B4fhird-Party <br /> International Code Council Certification#: p0057&3S Expiration Date: <br /> ALTERNATE 1 fional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Opfional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations,title 23, section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): 3HVo <br /> btlA £R EMR 1 <br /> \ 114fty ll•S.U.TpAs$• D�2dcT02• <br /> SIGNATURE OF TANK OWNER: /L�wY�4 //-__ 6M FSR 'RACY U.S,a. <br /> DATE: Ob I2 0%l Z OWNER'S PHONE#: 6ogj 367-4,02o <br /> November 2004 <br />