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12/14/2006 10:36 5107963470 SHARMA PAGE 02 <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 UST Requirements <br /> Facility Name: hAAltJ &Tf-LEY hKC.O A M A/1 Facility ID#; <br /> Facility Address: Beason for Submitting this Form(Check One) <br /> 11 p O 5• M h IN S'r 4l E T M A N TF.CA, C.A 9 5337 !( Change of Designated Operator <br /> Facility Phone i{: 2_o T L5 — 6-7 rb ti ❑ Update Certificate.Ex imtion Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operawr's Nwue: u.k R Relation to UST Facility(Check One) <br /> Business Name(f different from above):V ST S'fSTf-MS C)FE L A'tta. a Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone tl: 2 tag S l6— 4%$ (. ❑ Service Technician >(Third-Parry <br /> International Code Council Certification*., 52_(..164'1_5—UC- Expiration Date; l'1`0 <br /> ALTERNATE] (4 tional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from.above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: _ ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification 0: Expiration Date- <br /> ALTERNATE 2 (tlptlonal) <br /> Designated Operator's Name; Relation to UST Facility(Check one) <br /> Business Name(ff differentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> lntornational Code Council Certification 4: Expirution Date: <br /> NOTE=TIDE LOCAL)REGULATORY AGENCY MUST BE NOTIFIER 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,f 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,,S ENTF_KPKII E L I- G <br /> SIGNATURE OF TANK OWNER: <br /> DATE: l OWNER'S PHONE#: <br /> November 2004 <br />