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0 <br /> . San Joaquin County 0 <br /> Environmental Health Department <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <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: 5'L9eR S-rt P ,� 4„ Ld' Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> TE q G ❑ Change of Designated Operator <br /> Facility Phone#: 2-o 23 . t.I ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: A-i-Erq A iz v-4 A 1'Z, Relation to UST Facility(Check One) <br /> Business Name(If different from above): vA ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 2 09 — S1 _ t(936 ❑ Service Technician Molfhird-Party <br /> International Code Council Certification#: dC Expiration Date: <br /> ALTERNATE 1 O 'onal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(IfdifJerent from above): 11" ❑ 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 different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certificatio 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 • "Q A ' `4 <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S Pffgft#: 2-®moi - 2.3 9 — CII 4 I <br /> November 2004 <br />