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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 /> FacilityName: ••F i„cE.t, Facility ID#: A7OOo370 <br /> Facility Address: /5140 F4s f ✓cYizi i . 2Ao Reason for Submitting this Form(Check One) <br /> /-06; A• 9.io2 yo or Change of Designated Operator <br /> Facility Phone#: ��j-p 4) 3.1.3—8o P S ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY —ry <br /> Designated operator's Name: I nDpgt� W6II Relation to UST Facility(Check One) <br /> Business Name(Ifdii erent from above): t5FW-AZP .— .tom A.J TN0• ❑ Owner ❑ Operator ❑ Employee <br /> Designate10 or's Phone#: g!�o $ — ,303 Z Service Technician ❑ Third-Party <br /> International Code Council Certification#: 80f5175-4 -0C Expiration Date: 8—/9— Z612- <br /> ALTERNATE <br /> —/3- 2.0/2- <br /> ALTERNATE 1 O do <br /> Designated Operator's Name: Z-CE WAe0cl,-Y, Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner PKOperator ❑ Employee <br /> Designated Opemtor's Phone#: 96/j 735_8/!S SO!6 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 52 c/80/t) — Or— Expiration Date: 1Z-11V 20/2-ALTERNATE 2 (Opdo"O <br /> Designated operator's Name: Relation to UST Facility(Check One) <br /> Business Name Wdierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technichip.,.,_❑ 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 aboit twill " <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. /J / <br /> NAME OF TANK OWNER(Please Print): ✓7�F �or,>e� ��"`�'�"� <br /> SIGNATURE OF TANK OWNER: 1r 1r <br /> DATE: /1/.301 ZOlb OWNER'S PHONE#: �2a4J 333—$088 tC cS20 <br /> l ) <br /> November 2004 <br />