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0 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 /> Facility Name: Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> S-2-q tr YOSHMi TC AV- s <br /> Afl%C%C ��39 '33Fj ❑ Change of Designated Operator <br /> Facility Phone Xe4 _ 823 , 55M Update Certificate Expiration Date <br /> Designated UST ODerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: x J At - / Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above): fy0K(f}-L jl� sP�I'r CE ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ��1f-- 17- 12- 67-- ❑ Service Technician Third-Party <br /> International Code Council Certification#: q 7[J L Expiration Date: to ^ <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferentfrom 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(lfdrfjerentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Cl 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);, K-4gnd <br /> SIGNATURE OF TANK OWNER: <br /> DATE: t0(bY/2 C7/,!� OWNER'S PHONE#:620cl)110,9 <br /> November2004 <br />