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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 />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility° <br />Name: o' I S �-� �i Et ' <br />Facility ID #: <br />Facility Address: q j®® E,Gi n g i> <br />_ 5 eA 9 5 2%i <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 67-°9 *6 3 — .5"x-9 Al <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: ►'y7 /, /� <br />Relation to UST Facility (Check One) <br />❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different Irons above):Owner <br />Designated Operator's Phone #: CZ®I ?y6- Dodd <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 1 (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 front 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 fi•oni 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 />T 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 />^1 r // <br />NAME OF TANK OWNER (Please <br />DATE: 3 OWNER'S PHONE #: <br />November 2004 <br />