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0 0 *4 <br /> San Joaquin County RECOV D <br /> Environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA 95202 MAR 2 1 2008 <br /> Telephone(209)468-3420 Fax(209) 468-3433 ENVIP03NMENT HEALTH <br /> Owner Statements of Designated Underground Storage Tank (UST) <br /> ERVIS <br /> and Understanding of and Compliance with UST Requirements <br /> Facility ID#: <br /> Facility Name: <br /> Facility Address: x5r75 L t Reason for Submitting this Form(Check One) <br /> gt Change of Designated Operator <br /> Facility Phone=# 2o C& r 3 0 Update Certificate Expiration Date <br /> Designated UST ODerator(s) for thILEggift <br /> PRIMARY <br /> Designated Operator's Name: 6e P— Bn�—enh*e-�` Relation to UST Facility(Check One) <br /> Business Name(1fdifferentfrom above): kabkR4mklomret, 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone ihpoct) (P(),4 —q3,3(Q 0 Service Technician )<Third-Party <br /> International Code Council Certification 4:_ l5q U L Expiration I Date:,Jcv?.9 , 190 <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(1fdifferentfrom above): 0 owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification We: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF AW 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(§)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)app ic ble to underground storage tanks. <br /> NAME OF TANK OWNER(Please <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> November 2004 <br />