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J <br /> Owner Statements of Designated Underground Storage Tank (UST O era <br /> and Understanding of Compliance with UST Require m K Eft �iEALTH <br /> {j CES <br /> Facility Name:SHELL- 135816 Facility ID#: <br /> Facility Address:341 E MAIN Reason for Submitting this Form(Check One) <br /> Ripon,CA X Change of Designated Operator <br /> Facility Phone#:209-599-4454 ? Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Joseph Jimenez 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#:916-524-6972 ? Service Technician X Third-Party <br /> International Code Council Certification#:Temporary certificate Expiration Date: 12/29/2006 <br /> ALTERNATE 1 (Optional <br /> Designated Operator's Name:James Cusick 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#:916-524-6974 ? Service Technician X Third-Party <br /> International Code Council Certification#:Temporary certificate Expiration Date: 12/18/2006 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Denise Lees 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#:614-506-8201 ? Service Technician X Third-Party <br /> International Code Council Certification#:5243907-UC Expiration Date: 10/15/2006 <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). ®tL, QpD.2aj k <br /> SIGNATURE OF TANK OWNER: , co <br /> DATE: /k, OWNER'SPHONE#: <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 />