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r 17149%82615 Tait Envrlonmental Seryl16:41 a.m. 02-14-2011 2/3 <br /> I <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Shell OII Products Facility ID#: Shell Stockton <br /> Facility Address: 3515 Navy Dr. Reason for Submitting this Form(Check One) <br /> Stockton 95203 ❑ Change of Designated Operator <br /> Facility Phone 9: 26 9-e-(4(n- 69Lkl W Update Certificate Expiration Date <br /> Desienated UST Operator(s) for this Facility <br /> PRIAIARY <br /> Designated Operator's Name: Koftel,George Relation to UST Facility(Check One) <br /> Business Name(Ifdfferentfroor above): Tait Environmental Services,Inc. ❑ Omer ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.920.5387 ❑ Service Technician ® Third-Party <br /> international Code Council Certtfrcation#:5247982.UC Expiration Date: 1210 8/2 01 2 <br /> ALTERNATE 3(Optional) <br /> Designated Operator's Name: See Attached List of Alternates Relation to UST Facility(Check One) <br /> Business Name(Ifdlfj'erentfrom above): Tait Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: See Attached ❑ Service Technician N Third-Party <br /> International Code Council Certification#:See Attached Expiration Date: See Attached <br /> ALTERNATE 2 (Oprlorral) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdfferenifraa above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: ENpiration Date: <br /> I certify that,fpr 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 compliance with the requirements (statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks, <br /> NAME OF TANK OWNER(Please Print): mmiUEL (leAe-s <br /> SIGNATURE OF TANK OWNER: OF <br /> DATE: OWNER'S PHONE /4(0,5- <br /> NOTE:1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:wwtv.waterboards.ca.eovlust/contacts/eu0a aevs.hhnl. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> i <br />