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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 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance With UST Requirements <br /> Facility Name: YYFacility ID#: <br /> Facility Address:,x`1,35 ij*--� C-j`.E 6 kid, Reason for Submitting this Form(Check One) <br /> 5 k f A7; 9 sg-c 9� Change of Designated Operator <br /> Facility Phone#: J.c� _ (_05-9 75(® ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY _ <br /> Designated Operator's Name: p �� e Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner Operator ❑ Employee <br /> Designated Operator's Phone#: '8615-0/q- V0166 ❑ Service Technician_❑ Third-Party <br /> International Code Council Certification#: a J / - C Expiration Date: /® -b•-C) <br /> ALTERNATE I (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(/fdifferc:nt front above): ❑ Owner Operator ❑ Employee <br /> Designated Operator's Phone#: 05 -a /Q_ /,;t_ ❑ 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(Ifdifferent ft•ont 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 LIST 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): s E' a 1,eU/"t'I <br /> SIGNATUIRM OF TANK O ER:a• -s <br /> DATE:�_� 7—o OWNER'S PHONE#: <br /> November 2004 <br />