Laserfiche WebLink
San Joaquin County <br /> Environmental Health Department <br /> ., ton 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: V-1 VC`t>7 Facility ID#: <br /> Facility Address: LILA O C Reason for Submitting this Form(Check One) <br /> ❑ Chepi . � <br /> Facility Phone#: ;L G 4 v \ LA 2> 1- 11 Up Me E t <br /> Desiznated UST Operators) for this Facility SEP 0 4 2009 <br /> PRIMARY OVA"i io V,3 vcLC-(L- <br /> Designated <br /> LDesignated Operator's Name: Relation to USTI$ } q�eNckOGIN3�� <br /> pr�ibipL <br /> Business Name(/fdifferent from above):j/,��C-D ❑ Owner ❑ iCfp@ta�fbtC'VC5�1#'xp�pkgype <br /> Designated Operator's Phone#: O '7 t-1 L4 u l Z. 9- Service Technician ❑ Third-Party <br /> International Code Council Certification#: a,.Lk cl \ Expiration Date: 'J- --1-1 - \ l'7 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: -'Vl�Jn ej Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: a b �� LZ 19"Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: �v p <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: r-(�-:7 V"---C Relation to UST Facility(Check One) <br /> Business Name(If different from above):;[a LK ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: AA k-rjj�- VC---A Service Technician ❑ Third-Party <br /> Intemational Code Council Certification#: Z 1 3 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, fore facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designat d UST Operator(s). The individual(s) will conduct document monthly <br /> facility inspection and annual facility employee training, in accordan with California Code of <br /> egulations,title 2 , section 2715(c) -(f). <br /> Further e I understand and am in comp ' ce with the requirem nts (statutes, <br /> regulations,an ances) applicable to un ound storage anks. <br /> NAME OF TANK OWNER(Please Print . <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> November 2004 <br />