Laserfiche WebLink
F *age San Joaquin County <br /> )environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 �Fe <br /> Telephone(209)468-3420 Fax(209)468-3433 1 2004 <br /> u <br /> Owner Statements of Designated Underground Storage Tank (UST ;kbY(TH <br /> and Understanding of and Compliance with UST Requirements "SFS <br /> Facility Namc:Valley Pacific Petroleum Services,Inc_ Facility 1D H:FA0005584 `_ <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 930 E.Vidor Rd.,Lodi,CA 95240 Change of Designated Operator <br /> Facility Phone":(209)3343968 ❑ Update Certificate Expiration Uatc <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Mike Eliason Relation to UST Facility(Check One) <br /> Business Name(lfdtfierentfrorn above)Valley Pacific Petroleum Svcs,Inc. ❑ Owner ❑ Operator Employee <br /> Designated Operators Phone g:(209)993$_793 ❑ Service T'mhnician ❑ Third-Party <br /> Inlemalional Code Council Certificalio9&.4141014087 Expiration Date: <br /> ALTERNATE 1 fOpdonal <br /> Designated Operator's NanRobert Robertson Rclntion to UST Facility(Choek O,,) <br /> Business Name(1fdiiffi-mntlorn abOV7illey Pacific Petroleum Svcs,Inc. Cl Owner ❑ Operator Employee <br /> Designated Operator's Phone#:(209)327-8995 — - ❑ Service Technician ❑ Third-Party <br /> international Code Cuuncil Ccrtibcaron MROK00054 Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Desigmlal Operator's Name: Relation to UST Fncilhy(Check One) <br /> Business Name(ifAierentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated operator's Phone#: _..._ -_-- ---- ❑ Scrviec Technician ❑ Third-Party <br /> International Code Council Certification tt: Expiration Date: <br /> NOTE:TIIE LOCAL REGULATORY AGENCY kllus-f BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFOMMAT ION 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 hrlth the requirements(statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> . ... .. <br /> NAME OF TANK O\i'NF.t2(Please Print): (form C In P <br /> SIGN4TURF:OF TANK OWNER: <br /> DATE: 12/29/2004 OWNER'S PHONE M (209)948-9412 <br /> November 2004 <br /> VPPS Lodi COMM.max <br />