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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 ' DEC 2 0 2004 <br /> d <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Stockton Unified School District Facility ID#: N-808 <br /> Facility Address:1932 El Pinal Dr. Stockton, CA 95205 Reason for Submitting this Form(Check One) <br /> ■ Change of Designated Operator <br /> Facility Phone#: 209) 933-7050 ❑ Update Certificate Expiration Date <br /> Desihnated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Dan Mc Ilrath Relation to UST Facility(Check One) <br /> Business Name Valley Underground Tank Monitoring ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (209).649-8956. ❑ Service Technician ■ Third-Party <br /> laternational Code Council Certification t )M141012575 Expiration Date:Nov. 06 <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check Onc) <br /> Business Name(1f dri Brent front above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone : ❑ Service Technician O Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification t 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 in compliance with the requirements (statutes, <br /> Regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER Marilyn Domingo Stockton Unified School District <br /> SIGNATURE OF TANK OWNER 7XAtt---O-� /� <br /> DATE: December 15, 2004 OWNER'S PHONE #: (209) 933-7110 <br />