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"�'''Dec 28 04 01 : 19p LMH Facilities Management (209) 339-7672 p. 2 <br /> 0 <br /> 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: LP-rA pal HAL. 14wrmz, Facility ID#:fA-0600 513 <br /> Facility Address:9-Te-7 FAi rm(ml" Arm Reason for Submitting this Form(Check One) <br /> 1_4v; A 04-;Y0 )6 Change of Designated Operator <br /> Facility Phone#: *41 '�!y 4Y11 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:r4rAV,1 oZArt"k, Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: 141339-7"7 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 57NV36-7— t� Expiration Date: 2 ja(p <br /> ALTERNATE t (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent 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 dri ferent 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) -{fj. <br /> Furthermore,f 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): CsYvf4 <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 1.1, OWNER'S PHONE#: � 7y- <br /> Novem6er 2004 <br />