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San Joaquin County <br /> Environmental Health Department <br /> 1868 E. Hazelton Ave.,Stockton CA 95205 <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 /> f=acility Name *,—� �� Facility ID#: 4W4 42 <br /> ZfAC <br /> Facility Address: Reason for Submitting.this Fonn1(C'heck One) <br /> 35V$' W � ,` o(p ❑ Chance of Designated Operator <br /> Facility Phone#: �q ,�-,^t 66 _..._ update Certificate Ixpiratiois Date <br /> I)esi2imted UST Operator(s) for this Facility <br /> I'Ii1�I:�R1 <br /> Designated Operator's Name: hN Relation to UST Facility(Check One) <br /> Business Name WdiUPreni i•wn abovei: 4 D owler X Operator ❑ I mplocce <br /> Designated Operator's Nhrnie 'A—„.34o D Service Technicimt ❑ "third-Party <br /> International Code Council Certification#: � � Expiration Date: .3 <br /> AI-TE:RNATE I(Optional)_ <br /> ........_...... <br /> ..... <br /> Dcsi noted Operator's Name: Relation to USI'Facility(Check One) <br /> 13usiness Nunte(Ifd!(1imwfi•ont above):w P ❑ Ov%ner D Operator ❑ Employee <br /> Designated Operator's Phone#: Alov0 Sen ice 1,cchnician 1•hird-Party <br /> Internutional Code Council Certification#: .Sibs O Expiration nate: <br /> .11."I'E:RNATF.2 (Olrrional) <br /> —..._.._.. _---.. -- —-- .....�_-- .........._.__ _ .__ _..... .._... <br /> Designated Operator's Name: Relation to UST Facility(Cheek 0,,,, <br /> Busincss Name(!(Jt%ferent from chore): ❑ Omier ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Sen ice Technician ❑ Third-Part) "I <br /> International Code Council Certilication#: - 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 individtlal(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):/t/ps1 7re,r.+t,a����tt fr ' Ae ca. <br /> SIGNATURE. OF TANK OWNER: <br /> DATE: 7/16/2014 OWNER'S PHONE#: 916.753.6751 <br /> 7 3'2014 <br />