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San Joaquin County 0 <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 />PRIMARY <br />Designated Operator's Name: JOSEPH BAGLEy Relation to UST Facility (Check One) <br />Business Name (If &ffemMfrom ahave): BAGLEY ENTERpRISES, INC.o Owner 0 Operator 0 Employee <br />Designated Operator's Phone #: 209-367-4800 0 Service Technician )a Third -Party <br />International Code Council Certification#. 5297791—UC Expiration Date: 11/11/10 <br />ALTERNATE 1 COp6maO <br />Designated Operator's Name: JESSE BERUMEN Relation to UST Facility (Check One) <br />Business Name (If&ffemdfmn above): BA= ENTERPRISES, INC.o owner o operator o Employee <br />Designated Operator's Phone #: 209-367-4800 0 Service Technician NXThird-Party <br />International Code Council Certification #: 8014628 -UC tion Date: 11/11/10 <br />ALTERNATE 2 (OpfimmO <br />Designated Operator's Name: Relation to UST Facility (Check One) <br />Business Name (Ifdffeywdfrom abave): 0 Owner 0 Operator 0 Employee <br />Designated Operator's Phone #: D Semce Technician 0 Third -Party <br />International Code Council Certification Expiration Date-. <br />NOTE: THE LOCAL REGVIATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGF- <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 />NAAH OF TANK OWNER Mease Print): S.IC 'PIP -et qerj�jmns nilTiSir)n <br />SIGNATURE OF TANK 6WER:. r-fcx S17,ev '0XV <br />DATE: 'I'd413 2-0,0 OWNER'S PHONE #- <br />November 2004 <br />te) <br />