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0 <br />San Joaquin County 0 <br />Environmental Health Department <br />600 E. Main Street 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: (q t t-( 6� <br />FacilityID #: <br />Facility Address:�� G7r� <br />k 12y���'�'`�''"' <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: `7-0-11 3 co 4>----CX-+e cbr 3 <br />Designated UST OAerator(s) for this Facility <br />Designated Operator's Name: .LAS 1N t (AAA t--'1 <br />Relation to UST Facility (Check One) <br />rq- Owner ❑ Operator ❑ Employee <br />❑ Service Technician WThird-Party <br />Business Name (Ifdierent from above): PrL,4 <br />Designated Operator's Phone #: OW -1/1 <br />International Code Council Certification #: �-✓2 G�I� v C- <br />Expiration Date: t2 (22(t2 <br />ALTERNATE 1 t0ndonall <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 dierent from 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 One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If dierent from above): <br />Designated Operator's Phone #: <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 />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): 6a r-t�0-� -,5'M <br />SIGNATURE OF TANK OWNER: <br />DATE: l t I (02 OWNER'S PHONE #: I -A -e,3 y 8-C,LfD <br />November 2004 <br />