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San Joaquin County <br /> Environmental Health Department <br /> 600 E. Main Street Stockton 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 /> FacilityName: 1{WIK SeA\J Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> v) Cr 5. M /� S i t rtnJ r �f-Cr4 <br /> GA Q,_ 33 -4 ❑ Change of Designated Operator <br /> Facility Phone#: 2 L � — 2-35 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: 1-C,4,9.`�✓ /gi30 j- Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Zp ( — 5-18-— y 3G ❑ Service Technician 8--Mird-Party <br /> International Code Council Certification#: 5 a (p (o Lf 3— U C Expiration Date: CD 2- <br /> ALTERNATE <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii ferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ 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#: 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 am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. ` <br /> NAME OF TANK OWNER(Please Print): A I/ i .5'. 7- <br /> SIGNATURE <br /> SIGNATURE OF TANK OWNER: ` <br /> r q <br /> DATE: S/3 1 Le OWNER'S PHONE#: Za�� 4/cZ S / 2— <br /> November <br /> November 2004 <br />