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San Joaquin County <br />1vironmental Health Department <br />304 E. Weber Ave., Third Floor Stockton CA 95202 <br />DEC 2 8 2004 <br />ne -J 4T07YffT_(ZV9T-47"---3VnE_NW _, .. <br />r' <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name_�j� e (` t-o4C� i`�C3 + <br />Facility ID #:P4 0M -- <br />Facility Address: 232,0 o. ( poro'-do 'S k <br />�J�t7t V-4tDr1, GA. 1357-OLk <br />Reason for Submitting this Form (Check One) <br />VC Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: CZ,®q Qy3 - 13l \ <br />Designated UST Operator(s) for this Facility <br />Designated Operator's Name' o6 e -r-4 NA, LLA -4-2. <br />Relation to UST Facility (Check One) <br />i8( Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />"usinfess Marne fir;"';i jl; ren! fr-onx above): c <br />Designated Operator's Phone #: C;Z -) cts-1- q 5 1'j <br />international Code Council Certification #: L%AV, 000 tfo <br />Expiration Date: t °3iOla1 <br />ALTERNATE 1 (Ontional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different front above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check Otte) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different front above): <br />Designated Operator's Phone It: <br />International Code Council Certification #: <br />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) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): a6 ewr k 1� • L-cA.k'L <br />SIGNATURE OF w <br />1� • <br />November 2004 <br />