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0 0 <br /> 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 /> FacilityName: l,,/�t���L00 sfS /QMµ-®,L Facility ID#: <br /> Facility Address: �6/( y �J�Fi c I�,G�® 40 Reason for Submitting this Form(Check One) <br /> c4- ` Sj;o i S— ❑ Change of Designated Operator <br /> Facility Phone#: ?j ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: ,�( Q, ��G�!!/j¢,� Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ®y ❑ Service Technician Third-Party <br /> International Code Council Certification#: p ci j——(A L Expiration Date: V Z-®f z <br /> ALTERNATE 1 O bona[ <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdif�erentfrom above): ❑ 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(If differentfrom 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 tounderground storage tanks. <br /> NAME OF TANK OWNER(Please Print): )'7K S 9 tI-1 <br /> SIGNATURE OF TANK OWNER: - —�� <br /> DATE: 3/s�a-®®2- OWNER'S PHONE#: <br /> November 2004 <br />