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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 />91 " Wit *W17 <br />ft Ir =-M <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: ��V_0-85 <br />Facility ID 000 7` 9AS7 <br />Facility Address: �i-_ye4- <br />S,3 7A <br />Reason for Submitting this Form (Check One) <br />)r Change of Designated Operator <br />Q Update Certificate Expiration Date <br />Facility Phone M. <br />Designated JIST Qgtrator(s) for jhjj FACIIIIX <br />PRIMARV & A <br />Dosignatcd Operator's Name: WIjVff,�M <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator C3 Employee <br />M Service Technician )( Third -Party <br />Expiration Date: eef L3 X p%, <br />Business Name (ifdVerentfrom above); dM 4� <br />Designated Operator's Phonc #; 411,19 -:5 79 <br />International Code Council Certification. 4: /10 Llej4 <br />ALTYMNATF, I MwInnal) <br />Designated Operator's Name: &V4f & Z21LA <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />Q Sondco Tcchnician )V Third -Party <br />- <br />Expiration Date:1(,(l Z-7 ZOO 7 <br />Business Name (If dIfferentfrom above): <br />Designated Operator's Phone M,0 ql� —_gZ3.:�AC <br />or IJWW <br />International Code Council Certification #: 57,qjRq z zr <br />^X4AZM'MA%ILA (Upff a <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Business Name (ifdifferentfiom a"):AL,41=A-I 4FoW1A4WM6 0 owner 13 Operator LI Employee <br />Designated Operator's Phone #: !2L 62 a:zz �z EtE d E3 Service Technician )t Third -P" <br />International Code Council Certification 5'2,S67M !Z I Expiration Date: ;:Eu 7,0 `Z00 <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) - (0, <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tamp. <br />ARAM <br />November 2004 <br />8 'd S I 18'ON SISIdddhNI doodvkov:q 9002 <br />