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{ <br /> San Joaquin County <br /> EUViiro alai Health De tment SEC 1 <br /> 600 E.Mail$Street Stockton CA 95202 <br /> Telephone(2Q9)460-3420 Fax (209)4",M33 <br /> tter Statcmenis of Designated Underground Storage Tank(UST)rjperator <br /> and Undmtandiag of and Compi' r„e with LIST Requirements <br /> Facile idmnr: 14 Fsudlty <br /> j <br /> Facility try Realm Jtr 5wiffluing 011 FM Mftk One) <br /> Ch Of�1b1$lllltfd 6Re►Alti� <br /> Fadli ! � pate�crilficetC F,xlhlif Thus <br /> OWN>rs< ( [or!!lila gsefllty <br /> Pitt <br /> >9 Name(if dr> nW('irojro60e0.. / � Ownet, o ® or cl <br /> P� ErnPit7oe <br /> Dc*is 0wVor's Phone#; O Senicc Teahniciaa m7r1'sny <br /> C 1 Code Cowei)Cev04w iiw►A; p1,j"% EuplrApan£ietet I <br /> -ALT .1 <br /> I DU1 Opuaweg NAMCi TMIA60n to UST Facillty{Check Q_47-1� 1 <br /> RadE Nnmc(opmoftoaaabove). 0 b C employee <br /> i Desi _ s Plx>tso#' 4?/ �� %� �/b ❑ S Moe Techak4an Third Party <br /> p I f <br /> AL A'E 3 (009@"I <br /> 1 A9Mi 't iewe+e; X77 Re~)etioa to UST Facility tC 0m; <br /> No tjj. Jnr aDava): a Out 0 Oporafor fZ lWoloyee <br /> NW s Phare 0; 7� '� � � Scrvlak T�ia�► leer-Party <br /> Infti Codc Cormgs Cali <br /> NOT91 TM LOCAL REGVLAI'OIIt'Y AGENCY MVS?BE NOTIFIED OF.ANY FSS TO THIS <br /> INFORWTXQN WITFM 30 DAYS OF TOE CRAWL <br /> J I cartify that,for the facility indicAW at the top of this page,the individual(s) listed above will <br /> servo as DenjWted UST Operator(s). Tl>F individual(s)will conduct and document monthly � <br /> faci in6pactions and attlnual facility em�6oyw training, in acoordance with Calif®tltia Code of <br /> as,title 23,secdom 2713(c)-(f),1 ' <br /> ' Fu are,I rind ad"d am isMpbance with the requirements(statutes, <br /> + r ations,and local ordiaxato)sppli Q tp ergroustd stn tankL <br /> j N OF TANK OWNU(Rteasa ): � ✓" l <br /> SIGNATM OV TANK 0"11R, <br /> q.� �]- s 3 (®3 <br />