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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)468-3433 <br /> Owner Statements of Designated Underground Storage T (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address:t �S,�y Reason for Submitting this Form(Check One) <br /> t�Change of Designated Operator <br /> Facility Phone#: 17 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRD4ARY <br /> Designated Operator's Name: 0 CL t MA, Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: - — 8-05—LjG ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 tions! <br /> Designated Operator's Name: aJ° DkIPM <br /> Relation to UST Facility(Check One) <br /> Business Name(If d fferent from above): ' ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: C-176— ❑ 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(Ifdifferent 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 /> a <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: L / OWNER'S PHONE#: <br /> November 2004 <br />