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r <br /> EE:IJ\�� , <br /> AUG 3 0 �U!0 <br /> Owner Statements of Designated Underground Storag� jh �� ' a`rator <br /> JA <br /> and Understanding of and Compliance with UST equirements <br /> Facility Name: Marigold Shell Facility ID#: <br /> Facility Address 6131 Pacific Avenue Reason for Submitting this Form(Check One) <br /> Stockton, California 95207 Change of Designated Operator <br /> Facility Phone#: 209-952-4862 x Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Kathy Kotulak Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): Hemmen Consulting, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 925-413-7422 ❑ Service Technician x Third-Party <br /> International Code Council Certification#: 5240722-UC Expiration Date: 8-6-2012 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: 7777-1 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <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 am in compliance with the requirements (statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Hung Thanhh Tran <br /> SIGNATURE OF TANK OWNER: `�' 2CO <br /> DATE: (� �� �� O OWNER'S PHONE#: 209-473-8205 <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: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />