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L San Joaquin County v <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: QT .v A/ Facility 1 )#: -ij 600,37Q <br /> FacilityAddress: /5!� �. ti ROA 0 Reason for Submitting this Form(Check One) <br /> i64. qswl/vX Change of Designated Operator <br /> Facility Phone#: S' &3.3- 8088 ❑ Update Certificate Expiration Date <br /> Designated UST Overator(s) for this Facility <br /> PRIMARY 'wA <br /> Designated Operator's Name: � 104'e&1E Relation to UST Facility(Check One) <br /> Business Name(Ifdieremfrom above): ❑ OwnerOperator ❑ Employee <br /> Designated Operator's Phone#: j�5-1 3S //s 5Q/(, ❑ ServiceTechnician ❑ Third-Party <br /> International Code Council Certification#: ,Z O/t7 —L!G Expiration Date: /220 71r6 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom 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 dierentfrom 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): l> 6910. /;& <br /> {(A/N <br /> SIGNATURE OF TANK OWNER: Y/�1AA17C a4,0i: ��L <br /> DATE: /Z�Z 08 - OWNER'S PHONE#: )333 .80238 6cr szoz- <br /> C6/N(f9s/ 947- A/71-3 <br /> November 2004 <br />