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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 /> Facility Name: l%AA IN STEGE T NKLO P, M P M Facility ID#: FA o o O -14-6 4- <br /> Facility <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> J�p0 S . MAIN STR-EET MANTEC.A� " 95337 'U Change of Designated Operator <br /> Facility Phone#: ?..pct g 25 — 6-1c6y Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: K A REN jk P,N A 1Z Relation to UST Facility(Check One) <br /> Business Name(If dii fereni from above):0 ST SySTE M S OP EIL A TOfL ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Z.,o9 S 1 S— 400, (e ❑ Service Technician Third-Party <br /> International Code Council Certification#: 2-(.(.4A.,—u c- Expiration Date: SF-?'r,-2.P q <br /> ALTERNATE l(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii feren(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(If different from above): ❑ 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 /> 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): LN)TEIkP(Z.1S E LL <br /> SIGNATURE OF TANK OWNER: �— <br /> DATE: 3 I 'L�1 g OWNER'S PHONE#: 2_6q) <br /> Z S <br /> November 2004 <br />