Laserfiche WebLink
FROM FAX NO. :12094627621 Am—b. 21 2006 03:39PM P1 <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 /> FacilityNalne: G041 00100C& TO Facility ID 4; <br /> Facility Address: %2.p_q tAa4Tkv-j R Reason for Submitting this Form(Check OV) <br /> VChange of Designated Operator <br /> Facility Phone 4: 0 update Certificate Expiration Date <br /> Designated U ST OpLratorfs)for this Facility <br /> PIUMARY <br /> Designated Operator's Name: AleX .7 Relation to UST Facility(Check One) <br /> Business Name(If different from above): Pfoo jon��/ Vjhowner c3 operator 0 Employee <br /> Designated Operator's Phone I ly—Z 2. El Service Technician S" hind-Party <br /> International Code Council Certification#; 52t1j-4"7— C— Expiation Dats: <br /> �; <br /> ALTERNATE 1 (000n41) <br /> Designated Operator's Name: Relation to UST Facility(Cheek One) <br /> Business Name(Ifd&rentfirom above): 11 Owner 0 Operator 0 FrnploYee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification 9: Expiration Date: <br /> AI,TERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Cheek One) <br /> Business Name(Idi&r,-n4frotn above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 4: 0 Service Technician 0 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): lb �A <br /> A.le <br /> SIGNATURE OF TANK OWNER:. <br /> DATE- OWNER'S PRONE <br /> November 2004 <br />