Laserfiche WebLink
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: Tracy 76 - Reliance Gas Investments, Inc. Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) d' <br /> 2420 W. Grantline Road, Tracy, CA 95377 �hange of Designated Operator "itu �� <br /> Facility Phone#: pending ❑ Update Certificate Expiration Date <br /> Owner Cell = (209) 481-7445 <br /> Desi nated US erator s for this Facility <br /> PRIMARY Pe <br /> Designated Operator's Name: kW&LEt: pC Relation to UST Facility(Check One) <br /> Business Name(If different from above): S — ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: )U q_b04 ❑ Service Technician A Third-Party <br /> Intemational Code Council Certification#: Expiration Date: <br /> ALTERNATE 1(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 /> Intemational Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> Intemational 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): '71 <br /> 1 <br /> SIGNATURE OF TANK OWNER: ' <br /> DATE: r� ` OWNER'S PHONE#: I-V <br /> November 2004 <br />