Laserfiche WebLink
Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Kayo Oil Company Site#2705445 Facility ID#: <br /> Facility Address: 1206 E.March Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95207 X Change of Designated Operator <br /> Facility Phone#:209478-6487 ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Jerry Zimowske Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:510-3644452 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#:5249080-UC Expiration Date: 12/1/2006 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name:See Attached Relation to UST Facility(Check One) <br /> Business Name(If different from above): X Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:See Attached ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: See Attached Expiration Date:See Attached <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:See Attached Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above):USTanx ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:530-268-3949 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:See Attached Expiration Date:See Attached <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 <br /> OR OWNER'S AGENT(Please Print): Stephen Boyd for ConocoPhillips <br /> SIGNATURE OF TANK s�J ^ <br /> OWNER OR OWNER'S AGENT: <br /> DATE: 2/15/2005 OWNER'S PHONE#: 714-428-6572 <br /> San Joaquin County Dept. of Health <br /> September 2004 <br />