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AP r. 27. 2007 2: 01 PM No. 0730 P. 3 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:ConocaPhillips Site270 64/1 9 Facility ID#- <br /> Facility Address- '32.02, 144K79 L4 Reason for Submitting this Form(Check One) <br /> S'rDclC"rCn,i CA <br /> X Change of Designated Operator <br /> Facility phone#:209—._ .. + ❑ Update Certificate Expiration Date <br /> Desiggated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:' SE Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above): ❑ Owncr ❑ Operator X Employee <br /> Designated Operators Phone#: l0 ;,"' 172 ❑ Service Technician 0 Third-Party <br /> Intmi mtional.Code Council Certification#: '3Q 413 C, Expiration.Date: <br /> A,]L'TMATIE E(ObdomqO <br /> Designated Opermtor's Name: Relation to UST Facility(Check'One) <br /> Business Name(Ifdiffierentfrom above): ❑ Owner fl Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Parry <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optionag <br /> Designated Operator's Name: Relation to UST Facility(Check One). <br /> Business Name(Ifdierent from above): ❑ Owner Cl Operator ❑ EmpIoyee <br /> Designated is Phone#; O Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:TSE LOCAL REGULA'T'ORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO TMS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> Y ceWfy that,for the facility indicated at the top of this page,the individual(s)Iisted 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 /> R,eguMons,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 <br /> OR OWNER'S AGENT(Please Print):�AOJA AJ�QgAM1ANA?i or ConoeoPhiffips <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: /,V1a OWNER'S PHONE#: _ 5 <br /> San Joaquin County Dept,of Health <br /> September 2004 <br />