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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 /> acility Name: 'l S Facility ID#: <br /> acility Address: / � Reaasson for Submitting this Form(Check One) <br /> sl/le A C',4/�'7 ,� M1 Change of Designated Operator <br /> acility Phone#: — 9 — Z Z ,�s ❑ Update Certificate Expiration Date <br /> Designated UST erator(s)for this Facility <br /> PRIMARY <br /> esignated Operator's Name: Relation to UST Facility(Check One) <br /> usiness Name(If different from above): �/q LLP �/N�e �Ieu�c� ❑ Owner ❑ Operator ❑employee <br /> signated Operator's Phone#: e c,. y ❑ Service Technician hird-Parry <br /> nternational Code Council Certification#: J j Expiration Date: d T1�1 �i3 <br /> liLTERINATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> usiness Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> esignated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> LTERNATE 2 (Optional) <br /> esignated Operator's Name: Relation to UST Facility(Check One) <br /> usiness Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> esignated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> OTE: THE LOCAL REGULATORY AGENCY MUST BE NO'T'IFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> certify that, for the facility indicated at the top of this page, the individual(s)listed above will <br /> erve as Designated UST Operator(s). The individual(s)will conduct and document monthly <br /> acility inspections and annual facility employee training, in accordance with California Code of <br /> egulations,title 23, section 2715(c)- (f). <br /> urthermore,I understand and am in compliance with the requirements (statutes, <br /> egulations,and local ordinances)applicable to underground storage tanks. <br /> AME OF TANK(OWNER(Please Pr21-k- <br /> 0' <br /> IGNATURE OF TANK OWNER: <br /> ATE: "er OWNER'S PHONE#: Q — � <br /> November 2004 <br />