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San Joaquin County aI/ <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 Compliance: with i LST RnquiLrmcnts <br /> Facility Name:Valley Paafic Petroleum Services, Inc__ FacilitylDth FA0003976 _ <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 1501 W.Charter Ma ,Stockton,CA 95206 Change of Designated Operator <br /> Facility Phone t:: ❑ Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRI\MARY _ <br /> Designatcd Operator's Name: Mike Eliason _ Relation to UST Facility(Check One) 1 <br /> Easiness Name(ljd erenr jrwn ebore)'Velley Pacific Petroleum SVCS, Inc. ❑ owEl �x Employe <br /> Designated Operator's Phone 9_(209)993-8793 ❑ Scrvice'rcchnieian ❑ 'lliird-Party Jill <br /> International Code Council Certification i'V4141014087 Expiration Date: <br /> ALTERNATE;1 fgpBonal)_ <br /> Desenated Operator's NaMcRobert Robertson Relation m I IS"r Facility(CbrrR One) <br /> Business Name(ljdi�reni ion,ahoiValley Pacific Petroleum Svcs. Inc. ❑ Owner ElOperator ,e( Employee <br /> Designated Operator's Phone il: 292 327-8995 ❑ Service Technician ❑ Third-Party <br /> Inrernational Code Council Cern ticm ion rROK00054 Expiration Date <br /> AUVERNATE 2 (Oprionul) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/jd irenl froru rtGore): —�— - -- ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ll: - -- -_ - - - - ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification 11: Expiration Date: <br /> NOTE;THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFOILMATION R'1TIHN 30 DAPS 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 Mvith the requirements(statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Norm CPM _ <br /> SLGNATURR'ovTANK OWNF.Rc.__j—_ <br /> DA'L'E: 12/29/2004 OWNER1SPHONEN: (209)948-9412 <br /> November 2004 <br /> VPPS Charter Way.max <br />