Laserfiche WebLink
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 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: �,�E S t v S 7 Facility ID#: <br /> Facility Address: �� L(ti tzReason for Submitting this Form(Check One) <br /> E Change of Designated Operator <br /> Facility Phone#: ;)_c �� — L� — (�L' ❑ Update Certificate Expiration Date <br /> Desienated UST Oaerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 75J,,_; �` ���t ;^ `J: Relation to UST Facility(Check One) <br /> Business Name(If different from above):(J i. " :� — ;, �.� Ili Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: �' _ ""- - c' �: <br /> L�--..� - S � ,�:�•- � � � Service Technician ❑ Third-Party <br /> International Code Council Certification#: L ,Lr _ GAQ_ Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1f different 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(Ifdifferent 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): S_A_ e V 2, 1A <br /> SIGNATURE OF TANK OWNER: <br /> DATE: S - '�S V { OWNER'S PHONE#: li J 4S 5 c'S <br /> November 2004 <br />