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E <br />L' <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 <br />Facility ID #:7A M z 77 <br />Facility Address: e4 <br />Reason for Submitting this Form (Check One) <br />A Change of Designated Operator <br />)s Update Certificate Expiration Date <br />Facility Phone M ® 9,35- 961477- <br />I UT] F=v 11,1101 n' marmi il T"n go <br />V1q1kV5Y:'V11V4 <br />Designated Operator's Name: A4 V6- L-: J) I LT= 2 Relation to UST Facility (Check One) <br />Business Name (If dlfferantfrom above): &ANMIJE Owner 0 Operator L3 Employee <br />LJ&AI C3 Technician Operator's Phone 0; EY <br />International Code Council Certification 3'R Q -7 — Expiration Date: j rd <br />T 'rVDAJAFrL' 'I 1A.9-11 <br />Designated Operator's <br />Business Name (tfdjftrenffr0M 4b0Ve):jAj <br />,d <br />Relation to UST Facility (Check One) <br />C] Owner 11 Operator 0 Employee <br />E3 Service Technician Thitd-Party <br />Designated Operator's Phone 4: 2 r <br />International Code Council Certification 7A 2 <br />Expiration Di <br />[WiT! 10 IN 0 W V Or MT7,741 <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />0 Owner a Operator L3 Employee; <br />u Service Technician 11 Third -Party <br />Business Name (11d0mntfrom above)., <br />Designated Operator's Phone #: <br />international Code Council Certification #: <br />I Expiration Date: <br />6MR, 1 0 01 A <br />40JET4 I (ONWAI V V I ICELIIJ M%Wlli <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 tanks. <br />SIGNATURE OF TANK OWNER; <br />O*NERIS PHNE #: <br />DATE. ghv/u O <br />711 <br />Nov=bcr 2004 <br />Z 'd £ I [8'ON SHIddhNl MdVMOV:9 900Z 11 -JEW <br />