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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 /> EFa <br /> lity Name: I�AAIN STOLE T A-(,C_0 P, M M Facility ID#: FAR o 0 c) -14-6 s� <br /> lity Address: Reason for Submitting this Form(Check One) <br /> 00 S • M{!IN S'rQ-E5T MAN 7EC/1C.A 9933] Change of Designated Operatorlity Phone#: Zpel ea �,5 61�t1 ❑ Update Certificate Expiration Date <br /> Designated UST Overator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: K A'R E N ARN A 17- Relation to UST Facility(Check One) <br /> Business Name(Ifdrfferent from above):VST 5'J.S%M S OPE To ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: L 09 5 t a— 4%3, (. ❑ Service Technician )< Third-Party <br /> International Code Council Certification#: 52,(e6 43-u C Expiration Date: C1 I 1-1 la <br /> ALTERNATE 1 (O tional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above):EE ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> gpe:tor's Name: Relation to UST Facility(Check One) <br /> fdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> tor's Phone#: ❑ Service Technician ❑ Third-Party <br /> e 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): K 1 S LNNTERPkl&E LL C_ <br /> SIGNATURE OF TANK OWNER: di <br /> DATE: I o OWNER'S PHONE#: (2_0q) V-5 — 6106L <br /> November 2004 <br />