Laserfiche WebLink
E E-,0 <br /> DEC 0 3 2008 <br /> Owner Statements of Designated..Underground Storage Tank (UST) Operator <br /> and UndA** Compliance with UST Requirements <br /> Facility Name:Valero,Food Mart Gasoline Facility ID#: <br /> Facility Address:2185 Fremont Street Reason for Submitting this Form(Check One) <br /> Stockton,CA. 95205 ❑Change of Designated Operator <br /> Facility Phone#:(209)390-5190 ® Update Certificate Expiration Date <br /> Desiynated UST Oaerator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Mark R Fairbanks Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209)754-1636 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:5243795-UC Expiration Date:September 16,2010 <br /> ALTERNATE 1 fflpfionaQ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdi,Q`erent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (O,peional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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): Joinder Lal Ram Rataan <br /> SIGNATURE OF TANK OWNER: ffl-I" <br /> DATE: _December 5, 2008 OWNER'S PHONE#:_(209) 390-5190 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.g_ov/ust/contacts/cupg Ms.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />