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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: fJ q S <br />Facility ID #: <br />Facility Address:l S. ,.„ ,� t,r.� `>1`7 <br />,;To C kr_- %J, -k CA- <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: ctte (, .- (o �, 3 3 <br />V C(tvlw(,c 04;- <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: �R ,� <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician I'Third-Party <br />Business Name (If different from above): 1-�E Stik a. a V, ..j <br />Designated Operator's Phone #: lyok _ 46 a _ SZo J <br />International Code Council Certification #: 5L5 LA'{ S — uL <br />Expiration Date: <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: .N R— <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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): L_,46,KT t?,,, as '_ L--C— <br />SIGNATURE OF TANK OWNER:Y-- <br />DATE:91Z3bo7 OWNER'S PHONE #: ( PQ -004, -loL3�1 <br />November 2004 <br />