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DEC 30 2004 4: 10PM HPAJ&ASERJET 3200 p. 2 <br /> San Joaquin County <br /> Environmental Health Department <br /> 304 E.Weber Ave.,Third Floor Stockton CA;95202 <br /> Telephone(209)4683420 Fax(209)468-3433 - <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: " eAFacility ID 0; <br /> Facility.Address:-+3+:s Uje-S Y1 Reason for Submitting this Form 1he k one) <br /> To R Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Design-ated•UST Operatorfs)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: J 22 Relation to UST Facility(Check orre) <br /> Business Name(lfdierent from above): ❑ Owner ❑ operator d Employee <br /> Designated Operator's Phone#: ❑ Service Technician 0 Third-Party <br /> MaInternational Code Council Certification#: f a1 y� Expiration Date ,200 <br /> ALTERNATE I (Optional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(lf dii Brent front above): ❑ Owner O Operator Q Employer"... . <br /> Designated Operator's Phone,#: O •Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (optional) <br /> Designated Operator's Nene: Relation to UST Facility(Check One) <br /> Business Name(1f diQerent from abom). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 4: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY A GENCX 1IUST BE NOTIFIED OF AN.Y:CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CTd uNGE. <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 individuals)will conduct and document monthly <br /> facility inspections and annual facility employee training,in accordance with.Cali.fornia Code of <br /> Regulations,title 23,section 2715(c)- (f). <br /> Furthermore,I understand and nen in compliance evith.the requirements(statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please rint) 1� e V ^' n 110y�-� <br /> SIGNATURE OF TANK OWNER• P <br /> DATE: OWNER'S PHONE 4: <br /> November 2004 <br />