Laserfiche WebLink
• <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 ComliiUST Requirements <br /> gr5i <br /> Facility NamFacit,'cy Add10878 NReason for Submitting this Form(Check One) <br /> Facility PhonChange of Designated operator <br /> Update certificate E (Add:`. terns€e) <br /> Expiration Date <br /> Desienated UST Onerator(s)for thla <br /> PRIMARY Facility <br /> Designated Operator's Name: JOSEPH BAGLEY Relation to UST Facility(C)jack One) <br /> BusinessName(K erenrf""nho )_ BALiIiESr ENTERPRISES IN �❑ Owner ❑ <br /> Designated Operators Phone#: 2 _ _ OPommr ❑ Employee <br /> International Code Council Certification#: ❑ ServiceTechmcim )M %rdp dy <br /> 5297791-UC Expiration Date: 11/11/10 <br /> ALTERNATEI <br /> Designated Operator's Name: JESSE BERITT'1t <br /> BusiRelation to UST Facility(Check One) <br /> ness Name(IJdrJjerentjro,aah-e):BAM,EY ENTERPRISES IN ❑ Owner ❑ O <br /> Designated Operator's Phone#: PI ❑ Employee <br /> 209-367-4800 ❑ Service Technicianan �ThirdParty <br /> Iaternanonal Code Coancil Certification#:8014628-UC <br /> ALTERNATE2 (Optio,ral) EaPrauonDate- 11/11/10 <br /> Designated Operator's Name: <br /> Relation to UST Facility(Check One) <br /> Business Name(IfdjJerentfromabovej: <br /> Desi sled ❑ Owner ❑ Operator ❑ Employee <br /> ga Operator's Phone#: <br /> ❑ Service Technicim ❑ Thud-Pally <br /> International Code Council Certification#: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF Exprafto _ <br /> ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> Frnore, <br /> that,for the facility indicated at the top of this page,the individual(s)listed above will Designated UST Operator(!). The individuals)willconduct and docum®t monEdnspections and annual facility employee training,in accordance with California Code ofons, title 23, section 2715(c)-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): Shawn Corporation <br /> SIGNATURE OF TANK 930141P. J7'ba --e- <br /> DATE!DATE: �OWNER'sPHONE M <br /> 32;?- <br /> November 2004 <br />