COMPLIANCE INFO_2004-2012 - Laserfiche WebLink

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San Joaquin County Environmental Health Department 600 E. Main Street Stockton CA 95202 Telephone (209) 468-3420 Fax (209) 468-3433 Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: V 5 Facility ID #: Facility Address: 1 0 r k it 0 S e-M'i Ni- 4ve s Reason for Submitting this Form (Check One) 1tV1t, t CA , TS 3 S 6 ❑ 9fiange of Designated Operator o/Update Certificate Expiration Date Facility Phone #: Z A Desianated UST Oaerator(s) for this Facility PRIMARY Designated Operator's Name: mo, 0L 4LM1: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee �3/Service Technician ❑ Third -Party Business Name (If dierent from above): �JDA x*)(- Designated Operator's Phone #: 2 S Z Z International Code Council Certification #: Expiration Date: ALTERNATE 1(Ontionah Designated Operator's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Business Name (If different from above): Designated Operator's Phone #: International Code Council Certification #: Expiration Date: ALTERNATE 2 (Opdonat) Designated Operator's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ❑ Third -Party Business Name (If different from above): Designated Operator's Phone #: International Code Council Certification #: Expiration Date: NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please SIGNATURE OF TANK OWNER: R -1v)c- DATE: j 1 e OWNER'S PHONE #: �Dj_ -7v November 2004