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.�. 1%d <br /> San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street 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 Compliance with UST Requirements <br /> Facility Name: (L'i alb;., Facility ID#: FA nooS846 <br /> Facility Address: a,rj�a Reason for Submitting this Form(Check One) <br /> L.7J;% (A Change of Designated Operator <br /> Facility Phone#: 7 pq- $3 5-3 i5 ❑ Update Certificate Expiration Date <br /> Designated UST Overator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: f +A yq�� Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 0%- 8-575- 3 5 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: �17 Sj,S_ u{- Expiration Date: - ��- <br /> ALTERNATE 1 tion! <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferent 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(If different 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: d-- d`S' �� OWNER'S PHONE#: �,�- L� <br /> November 2004 <br />