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44 <br /> 1 San Joaquin County <br /> Environmental ealth Department t i x , _ <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone(209) 468-3420 Fax (209)468-3433 ` <br /> j <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: us Caw Facility ID#: <br /> Facility Address: ( (_y3• (3t Reason for Submitting this Form(Check One) <br /> (-- , 11/5aq0 V Change of Designated Operator <br /> Facility Phone#: (,;, 8.7 -1 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <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#: j C. Expiration Date: J� J_�Cc,(� <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: �`®S r Relation to UST Facility(Check One) <br /> Business Name(Ifdii ferent from above): 7 syy� ❑ Owner Y Operator ❑ Employee <br /> Designated Operator's Phone#: QJ _Capp ❑ 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 different 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 /> 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)• k u tr <br /> SIGNATURE OF TANKf OWNER:S .I t <br /> DATE: % C `i OWNER'S PHONE th 0 - 1~t o1C10 <br /> November 2004 <br />