Laserfiche WebLink
3, <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Namc:Shell Facility ID#: <br /> Facility Address:7700 Moreland Ct Reason for Submitting this Form(Check One) <br /> Stockton,O 95212 X Change of Designated Operator <br /> Facility Phonel-,Q* 957-5398 a Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facili <br /> PRIMARY 'I <br /> Designated Operator's Namc:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name of different from above): #QL0LWvner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(209) 5184836 ice Tcehnician X Third-Party <br /> International Code Council Cern 6cation#:5266643-UC Expiration batt:07/16/09 <br /> AL'T'ERNATE 1 oRal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(ifdt,fferent from above): C7 Owner ❑ Operator Q Employee <br /> Designated Operator's Pbone#: El Service Technician Q Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> AL rERNATE 2 (Updional) <br /> Designated Operator's Nance: Relation to UST Facility(Check One) <br /> Business Narne(Ifdifferenrfromabove): ❑ Owner 0 Operator 11 Etnployce <br /> Designated Operator's Phone#: <br /> [2 Service Technician ❑ Third-Party <br /> Expiration Date: <br /> Intemmational Code Council Certification#: <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,l 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 ftint): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: ^02/08/08 OWNER'S PHONE -�~OWNER'S <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: vvww.waterUoards.ca.�ov/ust/contact/cu a s.h I. <br /> - 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />