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• 0 <br />San Joaquin County <br />Environmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />FacilityName: j' o p e (L `j -,v p / q -R k 6 % Facility ID #: <br />Facility Address: 2,qV , --n. Reason for Submitting this Form (Check One) <br />mfr,; c� , ,L B -"Change of Designated Operator <br />Facility Phone #: ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />r ruivllxim t <br />Designated Operator's Name: TO a_ C41 09-D <br />Relation to UST Facility (Check One) <br />❑__ `�Owner ❑ Operator ❑ Employee <br />CService Technician ❑ Third -Party <br />Business Name (If different from above): (4%& , C41 Prea I S, 0,a <br />Designated Operator's Phone #: �l 1 " � 1- -Z S �j % <br />International Code Council Certification #: 5 240 (p(a Lf — (A e— <br />Expiration Date: <br />Iry 1 in...:.,.,,n <br />Designated Operator's Name: -j E� � 6 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />[3 Service Technician ❑ Third -Party <br />Business Name (If different from above):C htkWj,2,CVn (Ijreeta,jofj <br />Designated Operator's Phone #0 (Ig C12--7—' j S!;7 7 <br />International Code Council Certification #: Nei- L{ r r REG,D Fay <br />Expiration Date: <br />ALTERNATE 2 (Optional) I <br />Designated Operator's Name: [ J ?—y �FRG S �40 O4.► <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />F*Service Technician ❑ Third -Party <br />Business Name( Ifdiferentfromabove)-Q% on Pt eeA1jjc,1j <br />Designated Operator's Phone #: - 2� —5 <br />International Code Council Certification #:j �Z D 52 <br />) , iKC_ <br />Expiration Date: l _C)t- <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 <br />SIGNATURE OF TANK OWNER: <br />GPHK tx) zA <br />6VTeRPj2_4s" <br />DATE: I'? c OWNER'S PHONE #: !it/ I <br />November 2004 <br />