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San Joaquin County RECEIVED <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 JUN 2 9 20 <br /> Telephone(209)468-3420 Fax (209)468-3433 ENVIRONMENTAL HEALTH <br /> Owner Statements of Designated Underground Storage Tank (UST) Oper / Vf <br /> CES <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility ID#: <br /> Facility Address: -7000 M XcA*,wSI.. CA*34ws Sxmb. Reason for Submitting this Form(Check One) <br /> fro-SAW-0 C 10 CA 45723 w Change of Designated Operator <br /> Facility Phone#: ❑ Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: ss$ wMf/,.3 Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician [Phird-Party <br /> International Code Council Certification#: 00 0 5719 3 Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ 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(If different 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 DE 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): OAKS M4CAW-)I 3TC, FL T <br /> SIGNATURE OF TANK OWNER: a C. RX. $ . <br /> DATE: /Z ea C), OWNER'S PHONE#: 7 - 4- d <br /> November 2004 <br />