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C7 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: 136186 <br />Facility ID #: 136186 <br />Facility Address: 3725 TRACY BLVD <br />TRACY, CA <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 209-835-7608 <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: Joel Crawford <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 9C Third -Party <br />Business Name (Ifdierent from above): <br />Designated Operator's Phone #: 916-420-2384 <br />International Code Council Certification M 5240664 -UC <br />Expiration Date: 08/12/2006 <br />ALTF.RNATF. t fnnernnntl <br />Designated Operator's Name: refer to backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (Ifthereat from above): <br />Designated Operator's Phone #: refer to backup document <br />International Code Council Certification #: refer to backup document <br />Expiration Date: refer to backup document <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: refer to backup document <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ® Third -Party <br />Business Name (/f dierent from above): <br />Designated Operator's Phone #: refer to backup document <br />International Code Council Certification #: refer to backup document <br />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 the requirements (statutes, regulations, and local <br />ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />SIGNATURY OFT OWNER• ' <br />• Aura ibley on if of Shell t P ucts S <br />Date:4L* Owne ' ne#: 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, 2007. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: hM //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 />June 2006 <br />