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San Joaquin County <br /> Environmental]Health Department <br /> 600 E.Main Street Stockton CA,95202 <br /> Telephone(209)468-3420 Fax(209)469-3433 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: �� Facility ID#: <br /> Facility Addresaq: Reason for Submitting this Form(Check One) <br /> a e,,2L 13Change of Designated Operator <br /> Facility Phone#: �9® � -r ' Update Certificate Expiration Date <br /> Deshaated UST Q eratorls for this 1Fa <br /> PRIMARY <br /> Designated Opctator's Name; '' L Relation Co UST Facility(Check One) <br /> Business Name(lf different from above): / J ❑ Owner Cl Operator ❑ Employee <br /> Designated Operator's Phone#: Service Technician 13 Third-Patty <br /> lntcraational Code Council Certification#: ^'� ,- v G Expiration Date; <br /> ALTERNATE 1D 'onal ✓ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator Q Employee <br /> Designated Operator's Phone#: C1 Service Technician ❑ Third-Patty <br /> International Cale Council Certification#: Expiration Date: <br /> ALTERNA,T>E 2 (Optional) <br /> Designated Operator's Name; Relation to UST Facility(Check One) <br /> Business Name(If differeta from above): O Owner ❑ Operator ❑ Lmployee <br /> Designated Operator's Phone#; ❑ Service Technician 0 Third-party <br /> International Code Council Certification Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST DIE 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 tot(s). The individual(s) will conduct and document monthly <br /> facility inspections and annual facility employee Mining, 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): <br /> SIGNATURE OF TANK OWNE. <br /> DATE: <br /> OWNER'S PHONE <br /> November 2004 <br />