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- w <br /> µ 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 Jail Facility (Generator) Facility ID#- <br /> Facili Address: Reason for Submitting this Form(Check One) <br /> 700 N. Michael Canliss Road <br /> Change of Designated Operator (Add:• t:erf3ate) <br /> Facility Phone#: Update Certificate Expiration Date <br /> Designated LIST QMratoK(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: JOSEPH BAGLEY Relation to UST Facility(Check One) <br /> Business Name(Ifc&f`erentfinma&—). BAGLEY ENTERPRISES IN .❑ Owner ❑ <br /> Operator ❑ Employee <br /> Designated Operator's Phone#: 209-367-4800 ❑ Service Technician XX Third-Party <br /> International Cock Council Certification#: 5297791–UC Expiration Date: 11/11/10 <br /> ALTERNATE I( <br /> Designated operator's Name: JESSE BERUMEN Relation to UST Facility(Check One) <br /> Business Name Qf&ffe—d jivxn abow):BAGLEY ENTERPRISES INC.0 owner ❑ opsrajhor a Employee <br /> Designated Operator's Phone#: 209_367-4800 ❑ Service Technician l�Third-Party <br /> International Code Council Certification#:8014628-uC Expiration Date: 11/11/10 <br /> ALTERNATE 2 (Optimal) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifd erentfram above). ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Coin Certification#: Expiration Date: <br /> NOTE:THE LOCAL REGULATORY AGENCY MUST BE NOTIMD OF ANY CHANGES TO THIS <br /> INFORMATION WITHIl1I 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 LIST 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 27I5(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 O (Pleme printy SJC Facilities Management <br /> SIGNATURE OF TANK OWNER <br /> loor <br /> DATE:_�� 0 O -S PHONE V. 468-4637 <br /> November 2004 <br />