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V'urvrl,��5 <br /> San Joaquin County <br /> Environmental Health Department L <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: Facility ID#: <br /> Facility Address: 33o,( W t14-rtn 64 L,,v, Reason for Submitting this Form(Check One) <br /> Change of Designated Operator <br /> Facility Phone#: )Q Gj j Update Certificate Expiration Date <br /> Designated UST OAerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: 6r_ 044A, (A Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): QU g57- 6sll ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: S, 6 ❑ Service Technician .R Third-Party <br /> International Code Council Certification#: Expiration 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-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(Ifdierent 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 /> 1 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 ap icable to underfround storage tanks. <br /> NAME OF TANK OWNER(Please Pri ): ( f C/�t�($r <br /> SIGNATURE OF TANK OWN <br /> DATE: ti OWNER'S PHONE#: Pf�� 72—d L& 7 <br /> i <br /> 3 <br /> November 2004 <br />