Laserfiche WebLink
7 2000 <br /> ENViRj,%z vit:NT HEALTH <br /> Owner Statements of Designated Undergro;Wgi+�QA�' (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Shell- 136186 Facility ID#: 136186 <br /> Facility Address:3725 TRACY BLVD Reason for Submitting this Form(Check One) <br /> TRACY,CA R Change of Designated Operator <br /> Facility Phone#:209-835-7608 0 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:Brian Ellsworth Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator El Employee <br /> Designated Operator's Phone#:916-524-6974 0 Service Technician W Third-Party <br /> International Code Council Certification#:5263224-UC Expiration Date: 7/7/2007 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:refer to backup document Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:refer to backup document 0 Service Technician R Third-Party <br /> International Code Council Ceifification :trr� �S!uv document Expiration Date:refer to backup document <br /> ALTERNATE 2 (Optional) j� <br /> Designated Operator's Name:refer-to'badky�ftument Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone-#: <br /> refer to Oment 0 Service Technician ®Third-Party <br /> International Code Council Certification#:re Meo backup document Expiration Date:refer to backup document <br /> I certify that,for the facility indicated at the top of this page,the individual(s)listed above will serve as Designated <br /> UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility <br /> employee training,in accordance with California Code of Regulations,title 23,section 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with th In ents(statutes,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> n <br /> underground n compliance <br /> d stor <br /> pua <br /> ag <br /> n <br /> e <br /> c <br /> tanks. <br /> e <br /> n1 <br /> 'I n I U, ents <br /> NAME OF TANK OWNER(Please Pr' Sh I Oil Products US <br /> SIGNATURE OF TANK OWNER. <br /> v i P <br /> A SilAey on be of Shell <br /> ,�P4,ducts I�S <br /> Date: 11/15/2005 er's Phone#: Main: 916-240-1610 <br /> HSE CC Cell: 916-240-1610 <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:hitp://www.waterboards.ca.gov/ust/contacts/ <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2005 <br />