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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 Sheriff's Operations Facility ID#: <br /> Address: Reason for Submitting this Form(Check One) <br /> %W N. Michael Canliss Road <br /> French Qmp, CA 95231 Change.of Designated Operator (AddAltertiate) <br /> Facility Phone#: Update Certificate Expiration Date <br /> Desiogted USTf <br /> QgLratoiAs) or this Facility <br /> PRIMARY <br /> Designated Operator's Name: JOSEPH BAGLEY Relation to UST Facility(Check One) <br /> Business Name(If&fferaWfrom above): BAGLEY ENTERPRISES, INC.0 owner 0 Operator 0 Employee <br /> Designated operator's Phone#: 209-367-48()o 0 Service Technician )U Third-Party <br /> International Code Council Certification#: 5297791—UC Expiration Date: 11/11/10 <br /> ALTERNATE 1(Opionao <br /> Designated Operator's Name: JESSE BERUMEN Relation to UST Facility(Check One) <br /> Business Name QfAfferedfrom above): BAGLEY ENTERPRISES., INC.0 Owner C3 Operator 0 Employee <br /> Designated Operator's Phone#: 209-367-4800 0 Service Technician MThird-Party <br /> International Code Council Certification#:8014628—UC T&*mfion Date: 11/11/10 <br /> ALTERNATE 2 (Op6mat) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdfferentfrom above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone 9: 0 Semce 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 WITHIN 30 DAYS OF THE CHANGK <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 trg,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 /> 4690W <br /> NAME OF TANKgRWEA(Please Pdnt): SJQ Fleet Services Division <br /> 'W- e <br /> Fav <br /> SIGNATURE OF TANK 9VRMR: 'rj <br /> DATE, lil OWNER'S PH®NEM 6,-,f <br /> November 2004 <br />