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4 <br />San Joaquin County 9 <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!er;tor <br />and Understanding of and Compliance with UST Requiremer�ifg:" <br />Facility Name: o A, j <br />Facility ID #: <br />Facility Address: <br />/J_ h�­ T lvh.� AV <br />Reason for Submitting this Form (Check One) <br />International Code Council Certification #: 0Expiration <br />❑ Change of Designated Operator <br />Facility Phone #: a105, - 73 <br />❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: ® <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdifferent from above): <br />Designated Operator's Phone #: % 73JL-1140 <br />International Code Council Certification #: 0Expiration <br />Date: Ia <br />ALTERNATE l (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 different 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 different 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): AIG <br />SIGNATURE OF TANK OWNER: 7 -� <br />DATE: i � /o54- OWNER'S PHONE #: Lrl� 1 `s -'7®o <br />November 2004 <br />