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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: San Joaquin County Public Works Corporation Yard Facility ID#: FA 3954 <br /> Facility Address:1810 E.Hazelton Avenue Reason for Submitting this Form(Check One) <br /> Stockton,CA. 95205 0 Change of Designated Operator <br /> Facility Phone#:209-468-3079 M Update Certificate Expiration Date <br /> Desienated UST Overator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Rick Tirapelle Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): 13 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:209-4684645 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:5249958-UC Expiration Date: 12/8/2008 <br /> ALTERNATE 1(OpdonaQ <br /> Designated Operator's Name:Daniel J.McCann Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner N Operator 0 Employee <br /> Designated.Operatoes Phone#:209468-3106 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:5249834-UC Expiration Date: 11/30/2008 <br /> ALTERNATE 2 (Oph <br /> Wnal <br /> Designated Operatoes Name:Joe Bagley Relation to UST Facility(Check One) <br /> Business Name(If different from above):Bagley Enterprises 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:209-3674800 0 Service Technician 0 Third-Party <br /> International Code Council Certification#:5297791-UC Expiration Date: 11/29/2008 <br /> 1 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 OFT OWNER(Please Print): Spay'Toa r Gr n 6 cs AA <br /> ye, <br /> SIGNATURE OFT OWNER: _ g, <br /> /IfC6411A. <br /> DATE:—to)/0/;PC6 OWNER'S PHONE#: 'OV9-f%S-JVF? <br /> J <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL,BOARD)By JANUARY 1,2. .THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: www.waterboards.ca.loy/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE <br /> November 2004 <br />