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0 0 <br /> San Joaquin County RECEIVED <br /> Environmental Health Department <br /> 600 E.Main Street Stockton CA 95202 JUN 2 9 2012 <br /> Telephone(209)468-3420 Fax (209)468-3433 <br /> ENVIRONMENTAL L <br /> Owner Statements of Designated Underground Storage Tank (UST) Opefmwrr/SERVICES <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: (tp0lz. Facility ID#: <br /> Facility Address: 119 I p E. gAReason for Submitting this Form(Check One) <br /> sT® tJ 5 Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: -SESSFELIL Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ird-Party <br /> International Code Council Certification#: ® 5 7& 35' Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different 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 di,f,}erent 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 /> r <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): PAW 11M1< CM0 It 5=F{.£e—, S <br /> SIGNATURE OF TANK OWNE ' �n QL?. $ V. <br /> or <br /> DATE: / / 12 OWNER'S PHONE#: 347^4-80 O <br /> November 2004 <br />