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• San Joaquin County • <br /> Environmental Health Department DEC 0 0 2004 <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> Telephone (209)468-3420 Fax(209) 468-3433 ENV! rr`j}.1 <br /> PF-- `=`1 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: D A L 7 to Facility ID#: 2 S.S J-7 <br /> Facility Address: J <br /> /"�C20 � • %OSG M STC .4+,`e - Reason for Submitting this Form(Check One) <br /> /V/A vT a LA C-A Gi S-31-3 el )( Change of Designated Operator <br /> Facility Phone#: '32-3 - '7(,-7c, ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: oto Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent f ono above): A. f A ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Z�0 _ `Q.) -76-73 ❑ Service Technician `jt Third-Party <br /> International Code Council Certification#: x t O 3 Expiration Date: /Z �fj O <br /> ALTERNATE. 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/f different ftoni above): Q/t,) ❑ 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(lf different fi-oan above): A—D Q A-7-e ❑ 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): Vi c.s !L-f C &Z:rN.4 <br /> ts:✓n uz ��sc <br /> SIGNATURE OF TANK OWNER: A4 r <br /> DATE: OWNER'S PHONE#: Zof-G0.7--1 *73 <br /> ",\�\ November 2004 <br />