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'Ib <br /> 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 Name: SJC General Hospital Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> 500 W Hospital Road <br /> FrepcL Camp CA 95231 M Change,of Designated Operator (Add.`4. Iternate) <br /> Facility Phone#: )g Update Certificate Expiration Date <br /> Designated UST42djs for this Facility <br /> PRIMARY <br /> Designated Operator's Name: JOSEPH BAGLEY Relation to UST Facility(Check One) <br /> Business Name(If&ffere&from above): BAGLEy ENTERPRISES 2 INC.0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone': 209-367-48W 0 Service Technician )a Third-Party <br /> International Code Council Certification#: 5297791—UC Expiration Date: 11/11/10 <br /> ALTERNATE I( <br /> Designated Operator's Name: JESSE BERUMEN Relation to UST Facility(Check One) <br /> Business Name(IfaVereWfroin aba%,): BA= ENTERpRISFS, INC.0 owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 209-367-4800 0 Service Technician INXThird-Party <br /> International Code Council Certification#:8014628—UC lExpiration Date: 11/11/10 <br /> ALTERNATE 2 (0pdax4 <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If afffemWfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITEOIN 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 traming,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): &33 doaquin G-eneral Hospital <br /> llj7 <br /> SIGNATURE OF TANK 'S—T. 19-VAX"t Hosys <br /> DATE' /-'j-/`-ear OWNER'S PHONE M 347— O 6 <br /> November 2004 <br />