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San Joaquin CountN' <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 <br /> Telephone(209)468-3420 Fax (209)468-3433 <br /> 0\vner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> I a:ilin \auto: � I I acilih !D : <br /> 1'ncilit, ;\dJrc.,. 4' / / Rcaaxon I.,r Submitlina this Form K•heck Ono <br /> 3610-5— /,4 <br /> ^ -✓ -P/! S-r.*, 6,4'. Sp?c) v clumite of Designated Operator <br /> I:,ctht, Phone —.S �p Update Certificate v.xpirmon Date <br /> Desianated UST Operator(s) for this Facilit\ <br /> PRI"IARY <br /> D,,i_na1cJ t,per:dor's\ante: _ Rehlian to I IST I:acililti 1C'htck Ohlel <br /> Itusines <br /> Name I If rlilli•rem Irr,er nhu,Yr: LiAargift,,i ❑ t 1„Iter ❑ Operator ❑ Emplo,rc <br /> ncsi nate)t q,erdor',Phnne _ 13lien icc Technician � Third-Pam <br /> International C,vlc C,amcil Certitic:uion I:y,ir two mae a / <br /> Al.rF:R\,%'1'F I (Optional) <br /> I lcsisnate,l c,I,eralor,Name (� , r ((elation to UST Facililc I Check One) <br /> ` I <br /> Ih„ines,Name lUdigrrrmlronrnlarrel.' tYip� Slto.�Olti S( ,C (Ntcr O Operalur ❑ I.ny,ln,ce <br /> De.i_naLJ t,perator's('hone-: <br /> 431k-921- a•4 _ a. Service I' mician X 'nerd-Part. <br /> Inlernnti,vt:dCndeGvnxilCcntli:anon S�S�lS�(o— UG IapiratitinDaw: <br /> :1L'f1:R�:\'fE? /Optbnroll <br /> I)c,ten:ted 1 tiler lo's Nance: I� ��4 i Relation la I IST Facililc witerk One) <br /> Nisiness Nmie IIldilkwon(turn chore): ❑ t \rwr ❑ 01wrat or ❑ 1:mplo\W I <br /> Desienated(,I,etator',PlioneIS 1 , ��f ' �.Sen'ice'rcchnician &_Thim-Path <br /> International C,Jc Council Certification S a� 1(�t_ y I` Fspirdion Datc: \ 1 <br /> NOTF:'1*11E LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CIIA\CES'r0 T111S 1 <br /> INFORMATION WITHIN 30 DAYS OF THF.CIIANGF.. l <br /> I <br /> I certif.' that. 1,61-the facility- indicated at the top of this page.the individual(s) listed above will <br /> sel"ve m Designated LIST Operator(s). The indiridual(s)uill conduct and document monthly <br /> facility inspections and annual facility employee training. in accordance\\ith California Code of <br /> Regulations. title 23. section 1-715(0-(f). <br /> Furthermore, I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> : <br /> NAME OF TANK OWNER(Please Print) <br /> ! l <br /> DATE.: 3 O 0W-Nt•:fi S 111101 F. <br /> i <br /> Noccnthcr_nn_I <br />