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1 0]33:27 p.m. 12-21-2010 2/3 <br /> 1714.9782515 Tait Envrionmental Servie • - - <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Faoility Nome: Shell OR Products Facility ID M: , Shea Stockton <br /> Facility Addroae:.3616 Navy Drt - Reason for submitting this Form(Check 011d) <br /> Stockton 96203 ❑ Charigo of Designated Oporator <br /> Facility Phone M: ❑ 13lictatoCortifioateExpimtiou Dsto <br /> Dealgpitted UST Ooeristor(s)for tbia Facility <br /> PRIMARY ,._._..- . <br /> Designated Opotator'aName: Hoffei,George Relation to UST Facility(Crack Ohe) <br /> Bnsiasat Nano o,W 0Ww;ifinm above): Tait Envlionmental Serviona,Inc, ❑ Owner ❑ Operator ❑ Employee . <br /> rmsigneted Operator's Phone N. 714.920.5387. ❑ Service Toolurician M Third-Parry <br /> .. ln1011141ional Code COdllail Cortication P:624798"C Expiration Data 12/02012 <br /> ALTERNATh I (Oplionap <br /> Designated Operator's Name: See Attached Ust of Alternates Relation to UST Facility(Chtek Orre) <br /> Business Name WdVr*nrJiunt dkcnv):. Telt Envkonmentar3arvloas,Inc. ❑Owner ❑Operator Q Employee <br /> DosignatedOperamrbPhonaNi SseAttsched ❑ ServicsTecliulw6i t4 Third•Party. <br /> tatentationul Code Councii Certification M;See Attached Expiration Datc: Sea Attached <br /> . ... ALTMATE2 (OPAaral)• <br /> Dowanatod Operator's Name: Relation to UST Facility(Check One) <br /> Business Namo.(IfdV4vV;1f0niabm,e): �^- ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone Ni ❑ Service Technician M Thin Party <br /> international Code Comoil Certification M: Expiation Dote: <br /> I certify that;for 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 amin compliance with the requirements(statutes, <br /> 1%gulatiogs;'and focal ordinances) applicable to underground storage tanks. <br /> NAME OF.TANK OWNER(Please Mat): COAisej <br /> l� ` �• t a • a i <br /> SIGNATURE OF TANK OWNER; C�+J .d�--�= <br /> DATE:��-d %�u/6 OWNER'S PRONE N:��G e��� fe y �f <br /> NOTE:I)SUBMrr THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL:BOARD)BY JANUARY 1,2003.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:i%ww watorboards:ca oi'/usUE411t4F S}!pa n vly s hhtil•. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION W MIIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />