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From Quest GSM to 4154855463 at 12/31/2004 4:56 PM 002/003 <br /> MDECEgVED <br /> JAN 0 6 2005 <br /> Owner Statements of Designated Underground Storage Tank (US41 UIN COUNTY <br /> and Understanding of and Compliance with UST Requirements MENTAL HEALTH DEPT <br /> Facility Name: Hammer Mini Mart Facility ID#: <br /> Facility Address: 3304 W Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton, CA 952194593 ■ Change of Designated Operator <br /> Facility Phone#: (209)951-8960 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Eric Wayne Garcia Relation to UST Facility(Check One) <br /> Business Name(If different from above): quest GSM D Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (925)756-1210 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#:5094004-UC Expiration Date: 11/24/2006 <br /> ALTERNATE l(Opdonap <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If di,fferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator',Phone#: D Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator'.Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner D Operator ❑ Employee <br /> Designated Operator's Phone#: D 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 <br /> OR OWNER'S AGENT(Please Print): AJ6 /S <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: <br /> DATE: ��i 30 OWNER'S PHONE#: y/f- 7210 <br /> September 2004 <br />