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14 <br />San Joaquin County <br />Environmental)Realth DeP'krtment <br />304 E. Weber Ave., Third Floor Stockton CA 95207. <br />Telephone (209) 468-3420 Fax (209) 468-3433 <br />Fals4on to UST FiFifi—y Lqs�k 904. <br />I T owner ri operaw Employee <br />1 t3 SavicaTechnicisn '�L Ibird-Pady <br />Expiration Date - <br />I tw&177 <br />W <br />Reladon to UST F=ifity Oeck 009) <br />a Owner a Operawr 0 Employee <br />0 SeMcaTechnician APM1rd-PWY <br />...... ...... <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed 460ve Will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />uty employee training, in accordance with Califfitnia Code of <br />,.facility irMections and annual faci <br />Regulations, title 23, section <br />Furthermore, I understand and am in compliance with the requirements (ststute$, <br />r�gulations, and local ordinances) applicable to unde M -round storage tanks. <br />NAME, OF TANK OWNER (Please Print): 4v, c' <br />SIGNATURE OF TANK OWNER: <br />DAM, OWNEWS PHONE #: <br />Z 'd H69'ON' S3S1HdhN3 dMdO NdH:6 90OZ '91'q9d <br />