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Dec 17 04 02:58p Rffda-Test (209) 794-0112 p.2 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 D E UC 2 0 2004 <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: '` ' Facility ID #: <br />Facility Address: Reason for Submitting this Form (Check One) <br />MEL , Ca )ntYLk i Q Change of Designated Operator <br />Facility Phone th— d Update Certificate Expiration Date 60 AW I <br />Designated UST Operator(s) for this Facility <br />PRIMAPY <br />Designated Operator's Name: L51$ wifflin O <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Teclutician ❑ Third -Party <br />Business Nanie (Ifdifferent from above) A VOf"da • T4$'4' <br />�DDee-sig—natedOperator's Phone #: ( zQ q) 7 q N - 0O 2 <br />rry�1 <br />International Cock Council Certification #: N = K ® Vi 0 I{ <br />Expiratton Date: I?_ % OLP j <br />'-LL l Z' rLwi, 1 b i fypaomw <br />Designated Operator's Name: i Relation to UST Facility (Check One) <br />Business Name (If cfrfferent from above): ❑ Owner O Operator u Employee <br />Designated Operator's Phone 0: � 13 Service Technician ❑ Third -Party <br />International Code Council Certification #: Expiration Date: <br />^- a c.auvw I c e tvpauf=t$ <br />Designated Operator's Name: <br />Relation to UST Facility (Check On(,) <br />❑ Owner O Operator ❑Employee <br />❑ Service Technician ❑ Third -Party <br />Basiness Name (Ifdiiferentfrom above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <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): . "'m- JAL'-�� , K <br />SIGNATURE OF TANK OWNER: v c�% _ _tel A.9 A ,4 <br />DATE: 1 L l / (Z it OWNER'S PHONE #: <br />November 2004 <br />