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Apr-29-09 02:53pm From- • T-112 P.02/03 F-508 <br /> • <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name; Shell Og Products Facility T#: <br /> Facility Address! 3514 Navy Dr. Reason for submitting this Form(ChaokOne) <br /> Stockton 95203 ❑ Change of Designated Opewor <br /> Facility Phone#: ❑ TJ�data CertiSeate iralion Datc <br /> Designated UST Operators) for this 1Fgcillly <br /> PRIMARY _ <br /> Designated Operator's Name: iCottal,Gear98 Relation w UST Facility(Chao*Ow) <br /> Business Namc((/diQ`erent from above); Tait Envlronmenlal Senftm,Itrc. ❑ Owner ❑ Operator ❑ Employee <br /> Designate$Operator`s Phone# 714.920.5387 0 Sorviox.Technician it Tolyd-Party <br /> Internmiond Code Council Certification#:5247M-UC Expiration Date: 12/1112010 <br /> ALTERNATE 1(Optional) - <br /> Desiguated 0pentoeti Name: See Attached Usl orAltarnaw Relation to UST Faciluy(Check One) <br /> Business Name(1140'eremfr6m above): Tait Environmental SeMces,1110. 0 OWD" ❑ Operator rt Employee <br /> DosignatedOperamr'aPhone#; SeeAllaehed ❑ Suvicr.Tcchoician N Third-Party <br /> Iuteroational Code Council Certification#:See Attached I Expiraii m Date: Bee Ataehad <br /> ALTERNATE2 (OptlonaD ^T_ <br /> Designated Operator's Name: Relation to USTPeaility(Check One) <br /> Easiness Name(1fd((ferentfroi,iabove): 0 Owner o Oporator ❑ Employee <br /> Designated operator's Phone W: O SmIce Technician 0 Tbsrd-P" <br /> international Core Council Certification#: Rxpiratioa Date: <br /> I certify that,for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as))osignated 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(Pleaas Print)! Miguel Torras A <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2 OWNER'ePHONE#: <br /> NOTE: 1)SUMT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL.AtANC1'LIST IS AVAILABLE <br /> AT:vnvw.w4kdoirds ca nov/usllrmrtaots/cuna sffrvslttml <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS LNFOMivIATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />