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7149782515 022 P.M. 05-17-2012 2 13 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name:Shell Oil Products Facility ID 9: Shell Stockton <br /> Facllity Address: 3515 Navy Dr. Reason For Submitting this Form(Check One) <br /> Stockton 95203 ❑ Change of Designated Operator <br /> Facility Phone 4: 9.41Cr(a—fir 4 4 t m Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRMIARY <br /> Designatcd Operator's Name: Koffol,Gnorgo Relation to UST Facility(Cherk Otte) <br /> BusinmsName(1f d�(ferenl jrorir above): Telt Environmental Services,Inc. ❑ t AN= ❑ Operator ❑ Employee <br /> Designated Operator's Phone 4: 714.92(1.5387 ❑ Service Technician 0 Third•Party <br /> International Code Council Certification 4:5247982-UC Expiration Date: 12/0812012 <br /> ALTERNATE i(Optional) <br /> Designaied Operator's Name: See Attached List of Alternates Relation to UST Facility(Check One) <br /> Business t3ame(Ifd�ffererrt frnm above): Tall Environmental Services,lnc. ❑ OiNmrr ❑ Operator 0 Employee <br /> Designated Operator's Phone J.- See Attached ❑ Service Technician 29 Third-Patty <br /> Intemational Code Council Certification 9:See Attached Expimtion Date: See Attachod <br /> ALTERNATE 2 (OptfonaIj <br /> Designatcd Operator's Name: Relation to UST Facility(Check One) <br /> Business Name @'differentfroin ubovc): ❑ Owner is Operator ❑ Employce <br /> Designated Operator's Phone 4: Cl Service Technician ❑ Third-Party <br /> International Code Council Certification 4: Expiration Date: <br /> I certify that,fqr 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 colnpliance with the requirements (statutes, <br /> regulations,wid local aedinahces)€igpli6ble to ifhd6rgfoufid storage tacks. <br /> NAME OF TANK OWNER(Please Print): 141&v L o � <br /> SIGNATURE OF TANK OWNER: v <br /> DATE: OINNER'S PHONE 0: <br /> MOTE;1)SUBMIT THUS COMPLETED FORAI TO THE LOCAL AGENCY(NOT THE STA'T'E WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT-.,,vwiv.waterboard,S.c-,i.gov/ust/contricts/cupa aRY1111ml. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 I <br /> I <br />