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San Joaquin County RECmWED <br /> Environmental Health Department SEP 2 4 LOIv_ <br /> 600 E. Main Street Stockton CA 95202 ENVIRONMENT HEALTH <br /> Telephone (209) 468-3420 Fax (209) 468-3433 PERM IT/SERVICES <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: (� ®FF rc5 ��S Facility ID#: <br /> Facility Address:7,00 MI G.. �1 J40, Reason for Submitting this Form(Check One) <br /> fp 2 Change of Designated Operator/4,0® L-T&AI)� <br /> Facility Phone<y0 -- Gt ❑ Update Certificate Expiration Date <br /> Designated UST QRerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: ti 6RF.,�thD e�/V Relation to UST Facility(Check One) <br /> Business Name(I(different from above): A9,4(,� ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:6,2® 1197-000100 <br /> [i�Service Technician V Third-Party <br /> International Code Council Certification#: �p1416,1k <br /> G`� (>L Expiration Date: ®/ 1112-016 <br /> ALTERNATE I (Optional) I <br /> Designated Operator's Name: tt}/Vi1�+$ P,+Y tDh/ - Relation to UST Facility(Check One) <br /> Business Name(If different from aboveA) ?jq ❑ Owner ❑ Operator ❑ Employee <br /> DesignatedOperator's Phone# D 9 6 P Ei-Service Technician P Third-Party <br /> S'd 6 766 6 Expiration Date: <br /> International Code Council Certification#: ^-(J� <br /> ALTERNATE 2 (Optional) <br /> Relation to UST Facility(Check One) <br /> Designated Operator's Name: <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 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): .S a 0,1 A) D A, <br /> C a Aou.f1`D D <br /> SIGNATURE OF TANK VR: 452 <br /> DATE: cr /2a/ OWNER'S PHONE# a / _ 3 t 16 <br /> November 2004 <br />