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Dec 30 04 11:03a 0 <br />209. 0q6 <br />.0214 P. l <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 Aq-rp Ce,-n-4,,�p..W <br />Facility ID tP F <br />Facility Address: 3�3� ti , ta„hr..`t-tMn- � 4-„ <br />Sm VeA-60-3'�-? ! I- <br />Reason for Submitting this Form (Check One) <br />Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: , 6'35 (o ,q Vt .E+0 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: LYI-je 'IJ !tilm () Relation to UST Facility (Check One) <br />Business Name (Ifdifferent fmm above): pt =rVS eD f2_0 ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: Z,05 3 5 4, p X Scrvice Technician ❑ Third -Party <br />International Code Council Certification #: f,41 IG, Gi Expiration Date: l lL ZOw <br />ALTERNATE I (Optional) <br />Designated Operator's Name: ?*,,i Relation to UST Facility (Check One) <br />Busines sName (If dierentfromabove): ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone 4: "7 95 . O e O ld Service Technician ❑ Third -Party <br />International Code Council Certification #: Q�► ®®' Expiration Date: t <br />ALTERNATE 2 (Ondorral) <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 different front above): <br />Designated Operator's Phone H: <br />International 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) - (f). <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): <br />SIGNATURE OF TANK OWNER: <br />DATE: <br />November 2004 <br />