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KI Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST requirements Facility Name: SHELL OIL PRODUCTS US Facility ID #: 136186 Facility Address: 3725 TRACY BLVD TRACY, CA 95376 Reason for Submitting this Form (Check One) ® Change of Designated Operator ❑ Update ICC # and/or Expiration Date Facility Phone #: 209-835-7608 Designated UST Operator(s) for this Facility Designated Operator's Name: Ian Moorhead Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician 0 Third -Party Business Name (Ifdifferentfront above): Gilbarco Veeder-Root Designated Operator's Phone #: 916-947-5285 International Code Council Certification #: 5250115 -UC Expiration Date: 10/31/2008 AT.TTi.RNATF, i (nntinnal) Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee . ❑ Service Technician ® Third -Party Business Name (If different from above): Designated Operator's Phone #: International Code Council Certification #: Expiration Date: ALTRRNATR 2 /nntinnal) Designated Operator's Name: Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician Q Third -Party Business Name (If different from above): Designated Operator's Phone#: Intemational Code Council Certification #: Expiration Date: I certify that, for the facility indicated at the top of this page, the individual(s) listed above Will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in regulations, and local ordinancesa p NAME OF TANK OWNER (Please rint): SIGNATURE OF TANK OWNS* ce�ffiith the requirements (statutes, underground storage tanks. DATE: 12/18/2006 OWNER'S PHONE #:'916-240-1610 Products November 2004