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�r San Joaquin County *010 <br /> Environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209)468-3420 Fax(209)468-3433 C <br /> 1 2i?�4 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with T JST Requirements <br /> Facility Name:Rapid Service Center _ Facility ID 4TA0010452 _ <br /> Facility Address: Reason for Submitting this Form(Cheek One) <br /> 3550 S. HWY 99,Stockton,CA 95215 X Change of Designated Operator <br /> Facility Phone 0:: ❑ Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Nime:Mlke Eliason — — Relation to UST Facdily(Check Ung) <br /> Business Name(IfAierenrjromnhore):valley Pacific Petroleum Svcs, Inc. ❑ Owner ❑ Operator X Emploync—I <br /> Designated Operator's Phone 8:(209)993-8793 ❑ Service Technician ❑ Third-Party JfI <br /> international Code Council Ceiti Ocaliont(4141014087 Expiration Date: <br /> ALTERNATE I (Opriono1) <br /> Desianated Opennor's NamRobert Robertson Relation In UST Farility(Check Ona) <br /> Business Name(lfdiffo eitffionr abetVglley Pacific Petroleum SVCS,Inc. ❑ Owner ❑ Operator X limployee <br /> Designated Operator's Phone/F 209 327-8995 ----__ ❑ Service Technician ❑ Third-Party <br /> International Code Council Certincatiun 1%I2OK00054 Expiration Dale: <br /> ALTERNATF 2 (Oprionnp <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name Uf(fierenifirun abore)r ---�� -__------- ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ll: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification If: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION)YITIIIN 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 Opciator(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, sectio)2715(c) -((). <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):Nonn Cru Q --- ---- <br /> SIGNA"1'URi:OFTANI<OWN Fat:,_— <br /> DATE: 12/29/2004 OWNER'S PHONE#: (209)948-9412 <br /> November 2004 <br /> Rapid Service Center.max <br />