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05/11/2014 00:59 FAX <br />2001/003 <br />Dec 21 04 11:53a Rf rda-Test 12L . 794-0112 p.2 <br />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 LIST Requirements <br />Facility Narttc: a oL �, -kA �- <br />Facility 1D 1#_ <br />Facility Address:(l_j II } C_ <br />Rcason for Submitting this Form (Check One) <br />International Code Council Certification #: N I K Q q <br />O Changc of Designated Operator <br />❑ Update Ccrtificatc Ex iradon Dace <br />Facility Phone #: C — �: <br />Designated UST Operator(s) for this Facilit <br />i�-��3neav <br />Designarod Operatar's Namc: L , e. N z tmm O <br />Relation to UST Facility (Gkcck One) <br />❑ Owncr ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Parry <br />Business Name (tfdi f eFent from above): A f T O fd IL - -rG s + <br />Designated Operator's Phone #: C20 co ri q a - a <br />International Code Council Certification #: N I K Q q <br />Expiration Data: 12 O Co <br />Al- 1Y;"A 1-Y:l (Upaunai) <br />Designated Operator's Name: _ f _ _ . Relation to UST Facility (Check Ona) <br />Business Name Qfdii ferent from above): _ ZA ❑ Owner O Operator ❑ Employee <br />Designated Operator's Phone #: ( 'i - ( A Scrvice Technician D Third -Party <br />International Code Council Certification #: Expiration Dare; <br />AL I CKJNA 1 L Z (Upaanai) <br />Designalcd Operator's Name; Relation to UST racility (Check One) <br />Business Narne (Jfdifferentfra?n above): ❑ Owner O Operator ❑ Employee <br />Designated operator's Phone a#: ❑ Service Technician u Third -Parry <br />International Code Council Certification #: Expiration Date; <br />NOTE: THE LOCAL REGULATORY AGENCY MOST BE NOTIFIED OF ANY CRANGES 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(e) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tftaks. <br />NAME OF TANK OWNER (Please Print):�IV- <br />SIGNATURE OF TANK OWNER: <br />DATE: 2r 2 ,L'Dq OWNIER'S PHONE ##: -M, — lnq ? S <br />November 2004 <br />