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San Joaquin County r <br />environmental Health Department <br />304 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 />Facility Name: Cf t; 4, r��.rf <br />Facility ID#: DOdZ?"+ <br />Facility Address: H y 0 }. /_ f.✓a r r2 �o v IZ. /. <br />L12GC4-tf^ C4 4j`2t <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: Z J - e/ r / - Z eS72) <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: Joel E. Crawford <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician R Third -Party <br />Business Name (Ifdierentfromabove): <br />Designated Operator's Phone#: 775-824-9008 <br />International Code CouncilCerification#: 5240664 -UC <br />Expiration Date: 8-12-06 <br />n -: <br />...,....,..1. .:., . <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifeli ferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />1 TGGNATG 2 /nnfinunA <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdiffierent from above). <br />Designated Operator's Phone #: - <br />International Code Council Certification #: <br />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 hme paid, for the facility indicated at the top of this page, the individual(s) listed above to <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 Stora a tanks, to the best <br />of ny krrw1e g9 ari v itb at inquiry am the d belay 6 <br />Vl <br />NAME OF TANK OWNER (Please Print): N e r n I� k0 F r V t <br />SIGNATURE OF TANK OWNER: <br />DATE: I Z y 0 OWNER'S PHONE #: <br />November 2004 <br />