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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 DEC '1004 <br /> Owner Statements of Designated Underground Storage Tank (UST) perato <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: A. Teichert Son Inc. Facility ID#FA0012107 <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 120 Frank 'West .Circle Stockton, CA 95206 ❑ Change of Designated Operator <br /> Facility Phone#: 209-982-4050 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George Takemor i Relation to UST Facility(Check One) <br /> Business Name(Ifdi f-erent from above): ❑ Owner ❑ Operator IN Employee <br /> Designated Operator's Phone#: 916—3 8 6—3 716 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification t 5241010—UC Expiration Date:0 8—2 4—0 6 <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dii Brent front 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 front 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).George Takemori for A. Teichert/Son, Inc <br /> SIGNATURE OF TANK OWNER: _,�eL <br /> DATE: <br /> 12-16-04 OWNER'S PHONE#: 916-386-3716 <br /> November 2004 <br />