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JAN-06-2005 12 :03 PM BAGLEY ENTERPPISES, INC. 209 367 5424 P. 02 <br /> Owner Statements of Designated Underground Storage Tank(UST)Operator <br /> and Understanding Of and Compliance with UST Requirements <br /> Facility Name: CAAng-11 ., —Facility ID#-. <br /> Facility Address-, 1224, MP4-rrWY ;L0, Reason for Submitting this Form(Check One) <br /> FwiftPhone#- <br /> %7&2,1 <br /> E3 Update Certificm Expiration Daft <br /> RNIU&J UST Onamfor(s)for ES& <br /> PRBIARY <br /> Designated OpemtWs Name: JOSEPH RAGLEY Relation to UST Facility(Check One) <br /> Rualnm Narne(Irdffmnrfrom above): aArrEyENTEj?,pRj=INC. 0 Owner 0 Operator 0 Employee <br /> DaWuftd Operstor's Phone#: 209-367-4800 13 Service Technician EIX nir&Party <br /> International Code Council Cerdfication# 5246988-UC Expiration Due: 11/29/2006 <br /> ALTE I Lopgqxgg <br /> Designated Operator's Name- Relation to UST Facility(Check One) <br /> Business Nam(ffgfifferentfrom above): M Owner 0 Operator 0 Employee <br /> Deeignated Operator's Phonic#: 13 Service Technician Cj Third-Party <br /> International Code Council Certification 0: Expiration Date: <br /> ALTERNATE 2 ftj!!L0 <br /> 1]0619ftated Operators Name- Relation to UST Facility(Check One) <br /> Bush=Name(Ifdfferewfrom above): 13 Owner 0 Operator a Employee <br /> Designated Operator's Phone#.- 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date. <br /> I certify that,for the facility indicated at the top of this Me,the individual(s)listed above will <br /> serve as Designated UST Operator(s). The individual(s)will conduct and document montlily <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 u"dCrxtR--d and RM in compliance with the requirements(statutes, <br /> regulations,and to ordinances)applicable to undergiround storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> _ <br /> SIGNATURE OF TANK OWNIM- <br /> DATE.11L.1--A OWNER'S PHONE#.-,69-d!V d6.2 <br /> NOTE:1)SUBMIT THIS COMPLETED FORK TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RMURCES CONTROL BOARD)By JANUARY 1,2M.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT.-v <br /> nMmaterbold5 c tML <br /> a.gov& e <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO TIUS INFORMATION WITHIN 30 DAYS <br /> OFTUR CHANGL <br /> November 2004 <br />