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ilec 31 04 02:22p Can a's Car Wash <br />(20 # 848 -1464 p.2 <br />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: h r j,., <br />Facility ID ti:F,4 -®Qp0 -.- Z e•' <br />Facifty Address:�p,� <br />Nff "[1 cU- q <br />Reason for Submitting this Form (Check One) <br />WX--+O; <br />O'Change of Designated Operator <br />0 Update Certificate Expiration Date <br />Facility Phone #: cl - {p <br />Designated UST Operator(s) for this Facility <br />PRI NI ARY <br />Designated Operator's Natne: y Cj atm C�� . <br />Relation to UST Facility (,Check One) <br />0 Owner ❑ Operator 0 Employee <br />0 Service Technician CP"Third-Party <br />Business Name ( different from above): <br />/f <br />Designated Operator's Phone f): q q — � — <br />International Code Council Certification f:: <br />Expiration Date: <br />ALTERNATE 1 Motional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 Service Technician ❑ Third -Party <br />Business Name (IfdifJcrent front above): s <br />Designated Operator's Phone 1h <br />International Code Council Certification #: <br />Expiration Date: <br />AUYLKINATEltttona ) <br />Designated Operator's Nantc: Relation to UST Facility (Check One) <br />Business Name (Ifdri ferent.fi•ont above): u ❑ Oevner ❑ Operator ❑ Fmploycc <br />Designated Operator's Phone 1J: 0 Service Technician ❑ Third -Party <br />International Code Council Certification d: Expiration Date: <br />NOTE: TILE LOCAL REGULA'T'ORY A,I,-'NCY MOIST BE NO'I TIED OF ANY CHANGES TO TEAS <br />INFORMATION WITHIN 30 DAYS OF THE CHA\GIE. <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): <br />SIGNATURE OF TANX OWNER: <br />DATE: /61�`3 -0 OWNER'S PHONE <br />November 2004 <br />