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DEC- -1 30 2004 <br /> Owner Statements of Designated Underground Storage Tek (UST) Operator <br /> and Understanding of Compliance with UST Rec� fem' t . <br /> Facility Name: SHELL- 136186 Facility ID#: 136186 <br /> Facility Address:3725 TRACY BLVD Reason for Submitting this Form(Check One) <br /> TRACY,CA X Change of Designated Operator <br /> Facility Phone#:209-835-7608 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:David Resnick Relation to UST Facility(Check One) <br /> Business Name(If different from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:925-743-1429 ❑ Service Technician X Third-Party <br /> Intemational Code Council Certification#:unavailable,passing report attached Expiration Date:not applicable <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name:Robert Boynton Relation to UST Facility(Check One) <br /> Business Name(If different from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:510-234-9600 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:unavailable,passing report attached Expiration Date:not applicable <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Mike Vander Plaats Relation to UST Facility(Check One) <br /> Business Name(If different from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:630-605-6737 ❑ Service Technician X Third-Party <br /> Intemational Code Council Certification#:5236491-UC Expiration Date:6/4/2006 <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): <br /> ZSIGNATURE OF TANK OWNER: 2 <br /> DATE: �L6� OWNER'S PHONE#: <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 />