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12/30/2004 15:32 209951 VILLAGE WEST Mt^` 1 PAGE 01 <br /> Sala Joaquin County C1 � [�'�` �'��'D <br /> Environmental Health Department <br /> 304 E. 'Weber Ave,Third Floor Stockton CA 95202 3 0 2Q04 <br /> . Telephone(209)468,3420 Fax(209) 468-3433 - <br /> E1JVil Ci��,)1% .IV1 HEALTH <br /> Owner Statements of Designated UndErground Storage Tank (UST) Operator's RVICES <br /> and Uliderstauding ofand Compliance with UST Requirements <br /> facility Name: 7" - ^—_ ---- . <br /> f=acility JD#:1~AOb 7j <br /> }(dtlt►11/1 7� Reason for Submitting this form(Check One) <br /> (r i �R-. <br /> TT�C. ❑ Chavg of Designated Operator <br /> Facility Ahone#: ❑ Update Certificate Expiration Date <br /> Desi >nated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: t,, Rclation to UST Facility(Check One) <br /> Business Namc(If rlifjerenr f�oru above): ❑ Owner ❑ Operator CJ Employee <br /> Dcsignated Operator's Phone : ❑ Service Technician /A Third-Party <br /> International Codc Council Certification M: Z .. Expiration Date: ` ��. 016 <br /> ALTERNATE. I (oltionR/ <br /> Designated Operator's Name: _ Rclation to UST facility(Check One) <br /> I3usiness Narnc(ljdjj,ent fro,,,ahorc) /7_ ,n-L <br /> ❑ Owner ❑ Operator ❑ 1:mpi�,ee <br /> Designated Operator's Pone h #: �- <br /> _ _ ❑ Scrvicc Tcchnician_40 -Third-Pavy <br /> International Codc Council CcrtiFcati , t; - <br /> _ ���'� _.�- Expiration Date: � .�.�—� <br /> AI;I'ERNATE Z (Optianai) ��r')� <br /> Designated Operator's Naune: - _ _^ Relation to UST Facility((heck Une) <br /> Business Namc(ljd,,%jcrc,nl fi1an shore): _ ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's'Phone fl: Q Service Technician ❑ Third-party <br /> International Code Council Certification ft: _ Expiration Date: <br /> NOTE: THE LOCAL RYGULATORY AGENCY AItiST T3E NOTIFIED OF ANY CHAN(;ES TO'TTII5 <br /> INFORMATION WITHIN 30 DAYS OF THE CHANCE. <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 doctimerlt 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 ttrnderground storage tanks. <br /> NAME OF WANK OWNER(Plense Print): <br /> .51GNATURE OF TANK OWNER: <br /> DATE: -- Q j OWNEf,2'S 17 ONE 0. `Z, 0 'Cf <br /> November 2004 <br />