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San Joaquin County <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 />Facility Name: <br />Facility ID #: <br />Facility Address: ! V I o SS „D A t E CA -'(1W <br />Reason for Submitting this Form (Check One) <br />)& Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: Z � — ,? S - K' <br />Designated UST Ouerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: K A -k F>N z <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician PO Third -Party <br />Business Name (Ifdierentfrom above): <br />Designated Operator's Phone #: b -E 8 <br />Intemational Code Council Certification #: Q , 2 y — U C • <br />Expiration Date: C 15-6 f <br />ALTERNATE 1 ftdonal) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If differentfrom above): <br />Designated Operator's Phone #: <br />Intemational Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdierent from above): <br />Designated Operator's Phone #: <br />Intemational Code Council Certification #: <br />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) - (fl. <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): '-TPA (— L C C1 /l <br />SIGNATURE OF TANK OWNER: �l <br />DATE: OWNER'S PHONE #:-9 7 9 ,� 7 -7 Y <br />November 2004 <br />