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�\ <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: Sheriff's Operations CTR #2 <br />Facility ID #: <br />Facility Address: 7000 N. Michael Canlis Blvd., <br />Reason for Submitting this Form (Check Otte) <br />French Camp, CA 95231 <br />Expiration Date: 11-29-06 <br />tX Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) 468-4637 <br />Designated -UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Joseph Bagley <br />Relation to UST Facility (Check One) <br />❑ Owner G Operator ❑ Employee <br />❑ Service Technician R7 Third -Party <br />Business Name (Ifdifferent fom above): Bagley Enterprises, Inc <br />Designated Operator's Phone #: (209) 367-4800 <br />International Code Council Certification #: 5246988—UC <br />Expiration Date: 11-29-06 <br />r:�wra:�cr_�r�ramrm M <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (Ifdiffcrent from above): <br />Designated Operator's Phone #: <br />International Code Council Certification M <br />Expiration Date: <br />t+1,1 atct4f% j c z runrrona[l <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee. <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different f •ont above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />tvU i h: I HE LOUAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 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 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 OF TANK OWNER (Please Print): Bob Cawelti fort,,San Joaquin County <br />SIGNATURE OF TANK OWNER <br />DATE: /0, •— 7ro t- Ej q- OWNER'S PHO' NE #c (209) 468-4637 <br />November 2004 <br />