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J-N-18-2005 .54 AM BC -LEY ENTERPPISES. INC. 209 367 5424 P. 04 <br /> Statements of Designated Underground Storage Tank (UST) Operator <br /> d Understanding of and Compliance with UST Requirements <br /> Facility N TRACY UNIFIED SCHOOL DISTRICT Facility ID#: <br /> Facility A 1975 W.LOWELL AVE. Reston for Submitting this Form(Cheek Ons) <br /> TRACY,CA 95376 X Change of Designated Operator <br /> Facility 209.031.5051 ❑ Update Certificate Expiration Date <br /> DeshEnated UST QRLrator(s)for this Facility <br /> Desi 's Name: 303MI BAOLEY Relation to UST Facility(Check One) <br /> A <br /> (Ifdr,�eremfro,aabove): BAGLEYENTERPRISLS, INC. ❑ (honer ❑ Operator ❑ Employee <br /> 5 Phone#: 209367.4000 a 9ervica Terdmielan X Third-Party <br /> c Camcil Certification# 5246908-UC Expiration Date: 11129/2006 <br /> 1 's Name' Relation to UST Facility(Check One) <br /> EU "ar.from above).' ❑ Owner ❑ Operator ❑ Employee <br /> Design is Pbanc#: ❑ Service Technician in Third-Party <br /> lnternatio4W&Council Certification#- Expiration Date: <br /> AL 2 (OPMaasq <br /> Desi is Name: Relation to UST Facility(Check One) <br /> Business (If'*ferenffrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Ducal is Phone#: ❑ Service Technician ❑ Third-Party <br /> In Council Certification#: Expiration Date: <br /> I certi for the facility indicated at the top of this page, the individual(s)listed above will <br /> serve ignated UST Operator(s). The individual(s)will conduct and document monthly <br /> facility tions and annual facility employee training,in accordance with California Code of <br /> R title 23, section 2715(c)-(f). <br /> Furthe re,I understand and am in compliance with the requirements (statutes, <br /> reguia .and local ordinances)applicable to underground storage tanks. <br /> NAME ANK OWNER(Please PH OHM l(tElHA - <br /> SIGNA OF TANK OWNER: ' <br /> DATE: 11 ws PHoNE* 209.321.3923 <br /> NOTE: MIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESO S CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: caw r v/ust/contacts/cu a agys.huni. <br /> 2)N LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF GE <br /> November 2004 <br />