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San dollquin County one <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 /> Facifity Name: Tracy Unified School District Facility m#: <br /> Fac' Address: Reason for Submitting this Form(Check One) <br /> 19 W. Lowell Avenue <br /> Changeof Designated Operator (Add;, ternate) <br /> Facility Update Certificate Expiration Date <br /> Desienated UST Ooerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: JUSEPH BAGLEY Relation to UST Facility(Check One) <br /> Business Name(Ifrbffemdfromabove): BAGLEY ENTERPRISES IN .❑ Owner ❑ Operator ❑ <br /> tx Employee <br /> Designated Operator's Phone#: ❑ ServiceTechnician XX Third-Party <br /> LdernationatCode council Certification#: 5297791—UC Expiration Date: 11/11/10 <br /> ALTERNATE <br /> Designated Operator's Name: JESSE BERUMEN Relation to UST Facility(Check One) <br /> Business Name(Ifdffemwfhxaaborr): BAGLEY ENTERPRISES ❑ owner ❑ Operator ❑ Employee <br /> Designated Operatoi s Phone#: 209-367-4800 ❑ ServiceTechnician XXThird-Party <br /> International Code Council Certification#:8014628—UC Expiration Date: 11/11/10 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If[k,Qerentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ ServiceTechnician ❑ Third-Party <br /> International Cnde Council Certification#: 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): Tracy Unified School District <br /> �a a frpd fVA <br /> SIGNATURE OF TANK O u <br /> PRS 7Y2�hcy L/SPy T�A►IS, DEPT <br /> DATE: /i k1W ae,4.0 OWNER'S PHONE#t: I .367— 4�a u <br /> November 2004 <br />