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*4w San Joaquin County y/ <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 E 3 1 2 1 <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: U514 --I.1- / / li <br />Facility ID #: <br />Facility Address: a 1-6 a 0.A.i(2050- hd <br />S 6 clo-•{p-L Jr a O rJ <br />Reason for Submitting this Form (Check One) <br />p< Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: c/ (o - Of a $ a <br />Designated UST Overator(s) for this Facility <br />PRIMARV <br />Designated Operator's Name: < <br />Relation to UST Facility (Check One) <br />❑ Owner a( Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdii ferent from above): S ,Q <br />Designated Operator's Phone #: D 5 <br />International Code Council Certification #: 5--V-13y I V- V C <br />Expiration Date: / O -5. a06(a <br />ALTERNATE I /Ontionah <br />Designated Operator's Name: 3-2g- -t s4- <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dii ferent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: - <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name Qfdii ferent from above). <br />Designated Operator's Phone #: <br />International Code Council Certification p: <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 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: <br />OWNER'S PHONE #: <br />November 2004 <br />