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r-X *2� 3 x-33 <br /> Owner Statements.of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST.Requirements <br /> 1~acility Name: Shell <br /> Facility TD#: <br /> Facility Address:7700 Moreland Ct Reason for Submitting this Form(Check one) <br /> Stockton, 95212 X Change of Designatod Operator <br /> Facility ph <br /> •(209)'957--sa8 ❑ Update Certificate Expiration Date <br /> 1 <br /> J <br /> Designated UT O erator s for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name:Karen R Arnaiz Relation to UST Facility(Check One) <br /> Business Name(Ifdeerentfrom above): <br /> d Owner 11 Operator ❑ Employee <br /> Designated Operator's Phone#:(20 9)518-4836 0 Service Technician X Third-party <br /> International Code Council Certification#:5266643-UC Expiration Date:0'7/15/09 <br /> ALTERNATE 1 D it'onaC <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(Ifdi�erent frons above); <br /> C7 Owner ❑ Operator la )Employee <br /> Designated Operator's Phone#: <br /> International Code Council Certification#: ❑ Service Technician ❑ Third-PartyE�cpiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: rrvliration <br /> tion to UST Facility(Check One) <br /> Business Name(If dffferenrfrom above); wner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ervice Technician ❑ Third-Party <br /> International Code Council Certification#: 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 individuals)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(e) -(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): ter 1'A � LA!�' <br /> SIGNATURE OF TANK OWNER; <br /> DATE: 02/08/08 OWNER'S PHONE#: r--Wt-F— ZO It It, –7 N--3 c1 <br /> NOTE: 1)SUBMIT TUB COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)HY JANUARY 1,2005.THE LOCAL,AGENCY LIST IS AVAILABLE <br /> AT:www.waxerboards.ca. uv/ust/contacts/cuoa agyitml, <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF TILE CHANGE. <br /> November 2004 <br />