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Owner Statements of Designated Underground Storage Tank(UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Sheriff Operation Center#I Facility ID#: FA 3787 Facility Address:7000 Michael N.Canlis Drive Reason for Submitting this Form(Check One) French Camp.CA.95231 0 Change of Designated Operator Facility Phone#:209-468-4645 E Update Certificate Expiration Date Designated UST Ogerator(s)for this FaSjjLq PRIMARY Designated Operator's Name:Rick Tirapelle Relation to UST Facility(Check One) Business Name(If differentftom above): 0 Owner E Operator 0 Employee Designated Operator's Phone#:209-4684645 0 Service Technician 0 Third-Party International Code Council Certification#:5248958-UC Expiration Date: 1218/2008 ALTERNATE I LOpyonalf Designated Operator's Name:Daniel J.McCann Relation to UST Facility(Check One) Business Name(If derentftom above): r-1 Owner 0 Operator 0 Employee Designated Operator's Phone#:209-468-3106 0 Service Technician 0 Third-Party International Code Council Certification#:5249834-UC Expiration Date: 11/30/2008 ALTERNATE 2 fflpCona J1 Designated Operator's Name:Joe Bagley Relation to UST Facility(Check One) Business Name(Ifdifferentftom above):Bagley Enterprises 0 Owner 0 Operator 0 Employee Designated Operator's Phone#:209-3674800 in Service Technician 0 Third-Party international Code Council Certification#:5297791-UC Expiration Date: 11/29/2008 I certify that, for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations,title 23, section 2715(c)-(f). Furthermore,I understand and am in compliance with the requirements(statutes, regulations,and local ordinances)applicable to underground storage tanks. NAME OF TANK OWNER(Please Print*%- SIGNATURE OF TANK OWNER: PI#'#44r/N7 DATE: is/a$` OWNER'S PHONE NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)By JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.jq�/ust/co�ntacts/cu�aa ys.html. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004