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From:1904749151 Page:1/1 Date:10/2412012 11:20.41 1AM �p <br /> Ar 4 ED <br /> REJEW <br /> NOV 16 2012 <br /> owner Statements of Designated underground Storage TaUk(US')OPOZAOUIN COUNTY <br /> and understanding of Compliance with UST ReqUirements ENVIRONMENTAL <br /> DIAgHEALTH DEPARTMENT nat9d UST rat® M E1_dHjj <br /> Facility N=c,Hammer 1-5 Arco AM PM Facility 11)0' <br /> Facility Ad&=: 3250 W.Hawn=LVL Reman for Submimst this Form(Check One) <br /> Stockton Ca 95207 0 Change of Designated Operator <br /> Facility PhWe 7-0 7r Lf Aly 2.. 0 Update Czrt&Uft ftiwfion Hate A <br /> PMEARY <br /> Designated OperaWs Nance:James Flowers Rdtb=to UST Facilky(Check One) <br /> Busiaaess Nance(df t above):Fran=-HM h= 13 Owner 13 (VMRW 0 EW10Yee <br /> Designated Opemtoes FhWe#-559-972-5087 X Sciy TcduAc4aa X Thind-party <br /> jgtanedCadeCcComcil Ce .cation 0;8036233-UC Expftatimlit : 1-26-13 <br /> ALTERNATE 1 okg2jap <br /> Designated Operator's Naftm Joshua Brown Relation to UST rawq(Check One) <br /> Busmss Name(1fdff-r-tf---b-*)Fmnzm HIM 0 Ownew 13 Operator 13 Employee <br /> SomceTedmidan x Tbadparty <br /> Desiguated OperoWs Phone 559-639-2977 <br /> humtkond CQft coua'ia S!!ti�00# 99f0 7.7 UQ I dation Date IV -zz- IYJ <br /> AL TE 2 W* <br /> DeApxed OperaW s Nam A42M Taylor Ralahon to UST F&dfitY(Check One)., <br /> Bu==Nme(rdVemtfivm abvw)t Aqwmn-ffiff. o oww 0 Op 0 Employee <br /> X SaviceTehidan XTbird-Farty <br /> nQs rho=p—Aw opatoeiv,mq-m-2rn <br /> fttmationg Co&-Council Ccrdfi=fion#-.-531 15?8-TJC Jon Date- 13 <br /> I ccxf4 that for the facility indicated at the top of this page,the individual(s)listed above will <br /> serve as Designated UST Opmmt0r(s). The individual(s)will conduct aad document mont* <br /> facility inspections and annual fadfitY employee ftWn& in 9L=rdanm with California Code of <br /> Regulations,tide 23, section 2715(c)-(f). <br /> Fur thermore,I understand and an in compliance with tht rcquilrtmeats(smt6tesi, <br /> regulations,and JOW ordinances)AppOCable to underground.stomge t=kL <br /> NAM OF TANK OWNER(Please Pd*): <br /> SIGNATURE OF TANK OWNER., <br /> DATE: OWNER'S PHONE#- <br /> NOW. <br /> .1)SuBbffr TM5 C0p&7LjgTM FO]RM To THE WCAL AGENCY(NOT 71M STATE WATER <br /> RES0111RClIKS CONTROL BOARD)BY JA"ARY 1,2oo.TBE LOCAL AGENCY LIST IS AV LE <br /> e .r'l lite <br /> AT: <br /> 2)NOTIPY THE]LOCAL AGENCY OF ANY CnANGEs TO TOTS TKFORMATION WITAIIN 30 DAYS <br /> OF THE CEBXG& <br /> 'ATt�sroml.os')MA <br /> This fax was received by GF1 FAXmaker fax server. For more information,visit: hftp://www.gfi.com <br />