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San Joaquin County � <br /> Environmental Health Department 1 �� �����' <br /> 304 E. Weber Ave.,Third Floor Stockton CA 95202 <br /> (J Telephone(209)468-3420 Fax(209)468-3433 JUN 2 2 2006 <br /> rc.l <br /> EV RC)�J EA-V HEALTH <br /> Owner Statements of Designated Underground Storage Tank (UST�p� y F-VICES <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName: AMMF_Q (U111,t l Mfg r j Facility ID#: <br /> Facility Address: 3}�(+ W (_kms F Reason for Submitting this Form(Check One) <br /> ,SYce KT-C,r`S r �� q,521`) ❑ Change of Designated Operator <br /> Facility Phone#: 51 sel b p ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRW A uv <br /> Designated Operator's Name: �E Q12� 1)►J6iE 4V P N3 Relation to UST Facility(Check One) <br /> Business Name(If di fferent from above): ❑ Owner ')� Operator ❑ Employee <br /> Designated Operator's Phone#: 0-c l) 9--1 1 Wo$ ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE l bona! <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 /> ALTERNATE 2 (Obdonah <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent 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 THF 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): ljNlN/k(�p�F�S <br /> SIGNATURE OF TANK OWNER: XVT���7 <br /> DATE: IkAL 7i I(A)6 , OWNER'S PHONE#: C 2�� �ci �'~� ceVb <br /> November 2004 <br />