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San Joaquin County RECENED <br /> Environmental Health Department bEP 2 4 1010 <br /> 600 E. Main Street Stockton CA 95202 ENVIRONiviffll HEALTH <br /> Telephone (209) 468-3420 Fax(209) 468-3433 PERMIT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: <br /> —(ZZ A,)0 W,0. Facility lD#: <br /> Facility Address: 1g,1V AVE Reason for Submitting this Form(Check One) <br /> Sly� /j , C_- 4 cir.2 D I &"Change of Designated Operator/&,4 M <br /> Facility Phone#: El Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: J6_U6 944140201,w Relation to UST Facility(Check One) <br /> Business Name(If different from above).8,+4,f,4C-)e' 0 Owner 0 Operator 11 Employee <br /> Designated Operator's Phone#:(gpg) _�4z—qeob W Service Technician Vr Third-Party <br /> International Code Council Certification#: 14Q,& (f C Expiration Date: 11k <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: J0111"IfJ- P4-Y 74 A.) Relation to UST Facility(Check One) <br /> Business Name(If different from above): Ae,4&ay g!E �, Mj�a. o Owner 0 Operator 0 Employee <br /> f WService Technician e Third-Party <br /> Designated Operator's Phone#(Aot !;�VD <br /> International Code Council Certification 7 j�6 0/ TExpiration Date: V/ <br /> 2-0 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 4: 0 Service Technician 0 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) - (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): (4,A) J 64a0i A) C=D 0A.4--1 <br /> e_Dpft_"& 0 <br /> SIGNATURE OF TANK 0MO: J-P <br /> DATE: !Z/Z�4/2010 OWNER'S PHONE 4j9& ?/a 6 <br /> November 2004 <br />