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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 DEC 3 1 2 J4 <br /> ENVIE;.;',"" <br /> Owner Statements of Designated Underground Storage Tank (UST)1Feperator; <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 5 g (p rj Facility ID#: Fl`4 pp D 3$15 <br /> Facility Address:a SCD W U `R�eason for Submitting this Form(Check One) <br /> �c �. 3 3 Change of Designated Operator <br /> Facility Phone#: q . 3- Nb ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:, ��Iyi Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner Operator ❑ Employee <br /> Designated Operator's Phone#: R' S -a lc4_ Qol,00 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5aq 90y1 & —U.C. Expiration Date: l O-S-acol- <br /> ALTERNATE l O tiona! <br /> Designated Operator's Name: S Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferenr 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(Ifdierent 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) lip licabllJe to underground)I storage tanks. <br /> NAME OF TANK OWNER(Please Print)• to F_ t C rQ S L1S e Q o�fm 1 <br /> SIGNATURE OF TANK(OWNER: e `�JJ <br /> DATE: �� 01 —O`1 _OWNER'S PHONE#: <br /> November 2004 <br />