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RECEIVED <br /> SL� 10 2 jj? <br /> Owner Statements of Designated Underground Storage Tank (UST# R6OPt TAL Hj� <br /> and Understanding of and Compliance with UST RequirementREAMir/SERVICEs��� <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 Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Kathy Kotulak Relation to UST Facility(Check One) <br /> Business Name(If different 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: 8-2-2014 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different 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 Thanh Tran <br /> SIGNATURE OF TANK OWNER: r Gt v GI cw::�7�IQ C"d <br /> DATE: — ��- 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.Pov/ust/contacts/cupa ag sem. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />