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Jan 24 05 11 : 29aP' 2 <br /> _.... _ -.... ., ��, u. i ¢rtrr 1O¢i, irvc. zov 5424 P-94 <br /> r <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Pa6lity Name: FAST a EASY 6 60 Pacility JD 0: <br /> Facllity,Addrc : 10876 N.HWY 99,E.FRONTAGE FID. Ramon for Submitting this Fonn(Check One) <br /> STOCKTON,CA 95212 ❑ ChmscofDesignmcdOpaseor <br /> Facility Fltone#; ❑ Update Cenifleale Expiradon Daic <br /> besianated UST Oocrstor(s)for this Facility <br /> PRIMARY <br /> Deslgnsicd Operator's Name: JOSEPH BAGLEY Relation to USTFaoillty(Check Orr) <br /> Rusmc�Namc(IJdtferonr/Mm above): BAGLEY EA'rERPRISFS,JNC. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operfftne5 Phone M: 209.367.4100 ❑ Service Techawian mr Third-Party <br /> Intr Tonal Code Counts CatiSeatim# 5246916-UC Expiredon Date:11/2912006 <br /> ALTERNATEI <br /> Designated Opwator2 Nemo: Relation In UST Faclllty(Chrck One) <br /> Business Name(1fd/femnifivn abow): ❑ Owns ❑ Opmaar Cl Employee <br /> Designated Opaetor's Phone#: ❑ Service Technician ❑ Third-Party <br /> lnkrnational Cede Connell Cer08catiun r: EapwWon Dale: <br /> ALTERNATE2 (Dp6mmV <br /> Designurd Operator's Name: Relation w UST Facility(Check Oar) <br /> Rualnem Name(If dfomarfiom abowr): ❑ Own= ❑ Operator ❑ Employee <br /> Deallnated Opmatar'a Phone a: ❑ Smice Technician ❑ Third-PMy <br /> Inatmatlonal Co&Couacil CertiArwdon# Expiration Dore: <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 Inde and storage tames. <br /> NAME OFTANK OWNER(Please Print): ASH ^ALI <br /> SIGNATURE OF TANK OWNER: <br /> DATE: JANUARY 20,2005 OWNS 'S PH N�#i 707.747,2955 <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www,waterbpWd$.ca.gov/tist/contac-t52cyva agys hrml. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 70 DAYS <br /> OF THE CHANCE. <br /> November 2004 <br />