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S F P a 2008 <br /> San Joaquin County FNViRU(vt'hBN I HE AST!! <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: 91an ei keVeon Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> �'y�l Cah,'taL �}Ye ❑ Change of Designated Operator <br /> Facility Phone#: ;Z p -3 3 y - O Q 7 J ❑ Update Certificate Expiration Date <br /> Desianated UST Operator(s) for this Facility <br /> PRIMARY _ <br /> Designated Operator's Name: A 1 e5y- JA(3/3,x}A 1 Relation to UST Facility(Check One) <br /> Business Name(fdifferent from above): l4anC4kfro%ue/ ❑ Owner ❑ Operator El Employee <br /> Designated Operator's Phone#: 925- 3 9'i- I 2. ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: l-13 7-V 'L. Expiration Date: 1 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lfdifferent from above): z ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International 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 /> 1 certify that, for the facility indicated at the top of This page,the individuai(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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> November 2004 <br />