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San Joaquin County is <br /> Environmental Health Department c <br /> 304 E. Weber Ave., Third Floor Stockton CA 95202 'tr <br /> Telephone(209) 468-3420 Fax (209) 468-3433 M <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: C 4S t2Fea( t Facility ID#: O <br /> Facility Address: V.;Lq rL yb S e m%i-e fde Reason for Submitting this Form(Check One) <br /> /17R7'i C0. -* 9-f-3-36" ,R�Change of Designated Operator <br /> Facility Phone#: ( 0 cl e.25-- ?2 Z ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 14 P,h Ea e Relation to UST Facility(Check One) - <br /> Business Name(IO dii ferent from above)r ❑ Osmcr ❑ Operator 16/Employce <br /> Designated Operator's Phone#: 64 o 2-3 o -m13-7113Service Technician ❑ Third-Party <br /> International Code Council Certification#: 14 0-0.9172- Expiration Date: // 1 f-/2 OT 6 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from 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(Ifeli ferenl from 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): <br /> SIGNATURE OF TANK OWNER: - --� � <br /> DATE: 12 Ze$F OWNER'S PHONE#(.2-91 )LS • 00-7722— _ <br /> November 2004 <br />