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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 Compliance with UST Requirements <br />FacilityName u ce eN-r,-,e /hgre <br />Facility lA W. <br />Facility Address: „7.01 e C'i 4A ret wAyRtason <br />STout'r'V C4 • /// Jr�Dfr, <br />for SWwrtitting this Form (Check One) <br />9K Change orf Designated Operator <br />0 Update Certificate Expiration Dale <br />Facility Phone #: Ro 7 367 O 0 5 <br />Designated UST ODerator(s) for this Facillty <br />PRIMARY <br />Designated Operator's Name:14 R PR CSC-- T S_ R <br />Rclation to UST Facility (Check One) <br />0 Owner �( Operator 0 Employee <br />Service Technician ❑ Third -Party <br />Business Name (If aVererrr from above): N j A _ <br />Designated Operator's Phoot #: P-09 ba 3,552❑ <br />Im"nabonal Code Council Cetiftcatioa #: r9 KC oc Q <br />Expiration Oak - <br />AL 161(f'VA I& i <br />Retation to UST Facility (Check One) <br />Designated Operator's Name: <br />Designated Operatnr's Phone #: <br />Business Name (If differentf-- above): <br />O Owner ❑ Operator o Employee <br />0 Service Technician Q Third -Party <br />Designated Operator's Phone #: _ <br />International Code Coruncil Cottification #: <br />4xpi'son Date: <br />At,lMMNPLlr L I MW <br />Designated operator's Name: <br />Relation. to UST Facility (Check One) <br />i.7 owner ❑ Operator ❑ Employee <br />❑ Service Tcchnicmn 0 'thud -Patty <br />Bush m Nx. (ifdiffcrexUfrom above): <br />Designated Operatnr's Phone #: <br />International Code Council Certification #: <br />Expuatim hate. <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIB.D 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 />scxve as Designated UST Operator(s). The individual(s) will conduct and doom wnt 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 tical ordiAaaces) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Prig): &O'C4, <br />SIGNATURE OF TANK OWNER: <br />DATE: /a o1i O OWNER'S PHONE M: L(90 9 O 0� <br />November 2004 <br />TO 3Jdd S3NI7 >Ionai oISSd-iD 89TZ6EZ60Z TT :ZZ bOOZ/6Z/ZT <br />