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San Joaquin County RECEVED <br /> Environmental Health Department 6EP 2 4 1010 <br /> 600 E. Main Street Stockton CA 95202 HEALTH <br /> Telephone (209) 468-3420 Fax (209) 468-3433 ENVIRONMENT RIVIIC S <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: G606A A 1-.- AA0S fr..4L- Facility ID#: <br /> Facility Address:5*0 vJ 44. Reason for Submitting this Form(Check One) <br /> ;=4 AJ EeeChange of Designated Operator/A A0 A -ICR m47E <br /> Facility Phone ^— 6 8/s <br /> ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: OC—C66 aE/Q()/1/1 C/v Relation to UST Facility(Check One) <br /> Business Name(If different from above): G&e A eklSi6 ❑ Owner ❑ Operator ®❑ Employee <br /> Designated Operator's Phone#:"17-3(07_1+F0 3 LYS Service Technician ® Third-Party <br /> International Code Council Certification#: *5 of(p"t 8 "'(1[. Expiration Date: <br /> ALTERNATE 1 (Optional, <br /> Designated Operator's Name: 6-5 P 7'�D/r/ Relation to UST Facility(Check One) <br /> Business Name(If different from above):18,4&to 64*A PRrsds ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone# ,meq 361— a 9KService Technician El'Third-Party <br /> International Code Council Certification#: sa 666 (} Expiration Date: C/ ! <br /> 2Q/ <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 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): S JC_ L J10'SP®-164 L <br /> U�-f�D C.-a X;;tAA- /t 40A,Sw C_ <br /> SIGNATURE OF TANK / <br /> DATE: /®�fi��l0 OWNER'S PHONE <br /> November 2004 <br />