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r <br /> I <br /> San .)oaquin County <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 <br /> Telephone (209) 468-3420 Fax (209) 468-3433 <br /> I <br /> 0WIllet' Statements of Designated Underground Storaue Tank (UST) Cperator <br /> and L nderstanding of and Compliance with UST Requirements <br /> I:r,ihl, C:unc: n I acilin 11) :' <br /> I'a:ilitt :\.Idre+.: j Re:laun for Sahnuuing 1111.FOrm tulw(A o,ny <br /> 3 Sas A✓ D": / <br /> 9sao t: ! it Change 4 Dcagnalc,l()permor <br /> I:.tlu, P1.111:c <br /> _ I1,klatc cerwie:rle I-cldnmolt talc <br /> Designated UST Ouerator(s) for this Facility <br /> PRI>L\R1 <br /> I1r+r_nalc.l(II,�Rrh r'.Name. <br /> I RclnUou tr,I!ST Facllil, (Chv(kOne; <br /> ro 'r P 1 )J k t►„ncr -2 /ilx al,rI v ticnlcc IMIllicmunwi,�nct:CrcicC,amcil Lcrrilic:ui.at Sii - (,(C FNI) ltion I)alc. a <br /> \I.TF:R�:\Tti I /OntinnrrQ _ <br /> I k,iul:u�d t rl,w':u,r',\noteG Relation u,UST Facility (Check omr/ <br /> L'u.mc..\ams 1/dilA•rrnr lru,u«bur.r • { t C• <br /> I Stn/tGrt .SfD.. OA. „kti p c.htncr f►I><r:uor ❑ I'Inldo.LL I <br /> I).•,i_natcJ t that;n;�r'.Nhonc -. <br /> Service le.chnictan Thud-Part. <br /> Imern:ni,n;d C,do Coun.it Ut-11 fical1­1i- <br /> S'�S'f5 <br /> I)c,r_nulcJ t ll,era 1,v's�•Inte: �' <br /> r-1 o f.0I:clation to PST 1'acili1% 1C'hel-A Uncj <br /> i tu.ine”`talus I l!&06oll/rum(Ibm'.1. <br /> I G I{ntptucec <br /> I)cniCnalca lll,etal.n'.1'Itnnc-, „�1 <br /> SIS 7 1 - �9�5 i �tierricc rccltnieidn �Third-Pam <br /> Inlc n;iti.nt;tl C.^dc Couuiil l'cnllicalion S �e (�l - V L h\t+irau.•n I)utc: I <br /> SOI F 'rtlF I OC:�I RF.G( I.:�I'OR1 1CF\C'\' <br /> MUST BE .\OTIFIFD OF a\1'CI1:I:VCF:S'PO Tllls <br /> `f�FUR1i-MOV 11ITt11\tDo.-\1'SOF"I'I'I F. Cli:1\GI•:. j <br /> f certify Ihat, len' the facihtv indicated at the top of this 1)a0"e. the indi\idual(s) listed abo\a \\ill <br /> Sel',e as Desll�nated UST Opermor(s). The Irldi,idual(s)\gill conduct and document 111011111h ! <br /> 1'16111, inspections and annual I'acilil% emplm ee training. in accordance„6th C'alilornia Code ol- <br /> ReQU1,10011S. title 2.1. section 2715(c)'- <br /> Furthermore, <br /> (c) -Furthermore, I understand and am in compliance with the requirements(statutes, <br /> re"Illations,and local ordinances) applicable to underground stora ge tanks. f <br /> OPT:\\K ON\'FIR (Please Prim)• �� 5 <br /> , <br /> SIGN VIA.RF.0F'1 1\\F:it: <br /> I)\ rt 30 � 0 O\\-,tTisl'IION F:a: �pC." <br />