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0 <br /> San Joaquin County 0 RECEIVED <br /> Environmental Health Department <br /> 600 E. Main Street Stockton CA 95202 JUN 29 2012 <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 /> Facility Name: !;Z'd— Facility ID#: <br /> Facility Address: CSOSAVA DPS'— "Sal S>i Reason for Submitting this Form(Check One) <br /> 'f MTc++ e- CP►+�►astS 43a,v D <br /> R I GN P CA t n"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: Jexr— SEAU'"YW 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#: 000 '5-7&3Expiration 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-Parry <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 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): SAX. 446£''L. Ff cn <br /> SIGNATURE OF TANK OWNER: Zt,1 emm^cxm rm y4aAaw= flow K <br /> DATE: 04A / Z, OWNER'S PHONE#: _ t 3 91-+000 <br /> November 2004 <br />