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M <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 /> Facility Name: ' p Facility ID#: <br /> Facility Address: 1 0 ff dnk C es- Ct ele Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone#: qj6--Z06-3716 ❑ Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: J S Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator >'Employee <br /> Designated Operator's Phone#: 116-3g6-1367 ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: 5592 L 054 —U C Expiration Date: DU. a <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: ` Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator X Employee <br /> Designated Operator's Phone#: qILM4-3716 ❑ Service Technician ❑ Third-Party I2�I QOl o <br /> International Code Council Certification#: 5 2y Uc I Expiration Date: 3 O l <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): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2_ / 3 -- O'� OWNER'S PHONE#: Q 1 L^ - .3 <br /> November 2004 <br />