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FROM RICK'S CHEVRON FAX NO. : 209-954-0582 Jan. 05 2005 01:50PM P2 <br />San Joaquin County <br />Environmental Health Department <br />304 F. Weber Ave., Third Floor Stockton CA 05202 <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 />FacilityName: iC,�� j , (f/�� ~4!F9:I—Facility ID 1{: <br />Facility Address: _r -g e_ Reason for Submitting this Form (Check one) <br />44 9-ra- 10 0 Change of Designated Operator <br />Facility Phone #; 2�0,� '7-7- Z ,i *,e 0 Update Certificate Expiration Date <br />Designated Opertaior's Narrtc: <br />Designated UST O erator s for this Facility <br />,4f,U c 2 - <br />Business Namc (!f dij1e.reni p opn above): <br />Designated Operator's nione 4: <br />Intemalional Code Council Certification #: _!5 4 --z< dr) z,-2_4 <br />DCSignated Operator's Name: <br />Business Name (lfd jPrepafrom above); <br />Designated Operator's Phonic 4; <br />International Code Council Certiticalion ft: <br />Relation to UST Facility (Check One) <br />I-I0%V,1Cr ppO N OMtor EmpIoycp <br />C3/Service Technician ❑ ThirdParty <br />lEXPiration Date: 12-/6 <br />Relation to LIST Facility (Check One) <br />n Owncr 0 Operator 0 Employee <br />❑ Service Technician ❑ Third -Patty <br />Expiration Date: <br />A1,TERNATE 2 (Optional) <br />Dcsignated Operator's Name: _ Relation to UST Facility (Check ()ne) <br />Business Name (Ifdifjerent from above): 0 Owner 0 Operator 0 Employee <br />Designated Operator's Phone #: _ �. 13 Service Technician ❑ Third -Party <br />International Code Council Certification: — Expiration Date: <br />NOTE: TRE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO TMS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br />I certify that, for the facility indicated.at the top of this page, the individt!al(s) listed above will <br />serve as Designated UST Operator(s). I'licA individual(s) will conduct and document monthly . <br />facility inspectimis 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. Vocal ordinances) applicable to underground storage tanks. <br />NAME OF TANK OVWi ER (PIease Print): C-) <br />SIGNATUM OF TANK OWNER: <br />DAIS: OWN'ER'S PHONE #: 77- 29 5 s,% <br />November 2004 <br />