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C <br />San Joaquin County <br />Environmental Health Department <br />600 E. Main St., 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: COUNTRY CLUB FOOD & FUEL <br />Facility ID #: FAo0019o9 <br />Facility Address: 1856 W. CUNTRY CLUB BLVD, STOCKTON <br />Reason for Submitting this Form (Check One) <br />it Change of Designated Operator <br />■ Update Certificate Expiration Date <br />Facility Phone#: 209-462-0652 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: CHRISTOPHER R. MILLER <br />Rel ationto UST Facility (Check One) <br />■ Owner ■ Operator ■ Employee <br />■ Service Technician 0 Third -Party <br />Business Name (If different from above): ADVANCED GEOENVIRONMENTAL <br />Designated Operator's Phone#: 209-467-1006 <br />International Code Council Certification #: 5250114 -UC <br />Expiration Date: 12/01/2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Narre. <br />Relation to UST Facility (Check One) <br />■ Owner ■ Operator ■ Employee <br />■ Service Technician ■ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification It. <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />■ Owner ■ Operator ■ Employee <br />■ Service Technician ■ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone#: <br />International Code Council Certification it. <br />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): FASSEL ELDER <br />SIGNATURE OF TANK OWNER: <br />DATE: ® OWN R'S PHONE#: 209-239-4347 <br />November 2004 <br />