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7149782615 08:00:53 a.m. 12-05-2012 2/3 UNDERGROUND STORAGE TANK SYSTEM OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS For use by Unldocs MemberAgencles or where approved by your Local./urisdictfon Authority Cited: Title23,Dlv.3,Ch.16 California Code of Regulations(CCR) FACILITY NAME FACILITY PHONE Shell Oil Products 01 ( Zo 9) q(.(, - V t41 FACILITY SITE ADDRESS CITY 3515 Navy Dr. Stockton REASON FOR SUBMITTING THIS FORM(Ched:One): Change of0eslgnated Operator UpciateoflCCCeNIRcatlon Erplratlon Datels) PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY DESIGNATED OPERATOR NAME George KOffel RELATION TO USTFACIUTY(Check one) BUSINESS NAME(Yotaecent lmm above);Tall Environmental Services, Inc. ❑ Ohmer ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE 714-920-5387 ext. ❑ Sewlec Technician Q Third-Party INTERNATIONAL CODE COUNCIL CERTIFICATION NO: 5247982-UC EXPIRATION DATE 11/28/2014 ALTERNATE DESIGNATED UST OPERATOR FOR THIS FACILITY(Optlonal) DESIGNATED OPERATOR NAME See Attached RELATION TO UST FACILITY(Check One) 0U51NESS NAME(1ldifferentlmm above): ❑ Owwcr ❑ Operator ❑ Employee DESIGNATED OPITAFOR PHONE I ) eXL 0 Sense Techniclnn _ Q Third-Party ................ ... INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE ALTERNATE2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME RELATION TO UST FACILITY ICheckOnr) BUSINESS NAME Wdiffecentfrom above): ❑ Oamer ❑ Operator ❑ Employee DESIGNATEDOPERATORPHONE ( ) ext ❑ Scrvice Technician ❑ Third-Pnrty INTERNATIONAL CODECOUNOL CERTIFICATION NOt EXPIRATION DATE ALTERNATE3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) BUSINESS NAME(Ifohlaahl imm above): ❑ Owner ❑ Operator ❑ Employee DESIGNATED OPERATOR PHONE ( ) ext. ❑ Service Techniclon ❑ Third-Pndy INTERNATIONAL CODE COUNCIL CERTIFICATION NO: EXPIRATION DATE I certify thnI,for the fact Itty indIanted at(he(ap of this page,QR IndividuAI(s)listed nbove will serve as Designnled UST Operator(s). The individunl(s)will conduct and document inanlldy facility Inspections and annual facility employee training in nccordnnce svilli Cnllfm•nia Code of Regulntions,Title 23,Section 2715(c)through(1). Purlhermorc,I underslnnd and nm in compliance with the requirements(statutes,regulntlons,and local ordinances)npplicnble to underground storage(1111m. TANK OWNER NAME 11/x,61, Ly9L—tp uc C3 TANKOWNERTITLE: .Kk/�1M� Mkky� OWNER PHONE C?i Cit"II-oo53 TANK OWNER SIGNATURE: '�blv`L,sy u/\ �— DATE: 12/3/2012 �—INSTRUCTIONS 1. Report the unnte(s)of the Designated UST Operator(s)as registered with the International Code Council(ICC).ICC certification info nintion is available on-line at:w9v)Y.ICCSRfe.org/e/ceriScarch.litml.Search for"California UST System Operators." 2. Submit this completed form to the local agency that regulates this facility's USTs.Unidocs member agency jurisdictions and contact information are listed on-line nt:www•.unidocs.arg/membershvhoregulnleswhaLhtnil.Contact infommtion for other local agencies within California is available at:wmvmv.smvreb.en.gav/ew•phare/ust/contRetsldocsAocni_ngcncy_lisl,sls. 3. 23 CCR§271 S(a)requires that you nail fy the local agency of any changes to this information within 30 days orihe date of change. UN-062-ill vimv.unidcP".org 08122/05 Received Time Dec. 5. 2012 8: 11AM No. 1782