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0 0 <br /> UNDERGROUND STORAGE TANK SYSTEM <br /> OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND <br /> UNDERSTANDING OF AND COMPLIANCE WITH UST REQUIREMENTS <br /> For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> A uthorio,Cite& Title 23, Div. 3, Ch. 16 California Code of Regulations(CCR) <br /> FACILITY NAME FACILITY PHONE <br /> Shell (209)403-3859 <br /> FACILITY SITE ADDRESS CITY <br /> 16500 S. Harlan Road Lathrop <br /> REASON FOR SUBMITTING I-HIS FORM(Check One): 0 Change of Designated Operator Z Update of[CC Certification Expiration Date(s) <br /> PRIMARY DESIGNATED UST OPERATOR FOR THIS FACILITY <br /> DESIGNATED OPERATOR NAME: Nikola Zagorov RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(lfdifferentfromabove): ECO-CHEK Compliance El owner El operator [:] Employee <br /> DESIGNATED OPERATOR PHONE: (888) 500-2435 ext. 2 [:] Service Technician Z Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 5264361 - UC EXPIRATION DATE: 06/25/2013 <br /> ALTERNATE I DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: A. Steven Abano RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME Qfdifferentfirom above): [--] Owner Roperator [:] Employee <br /> DESIGNATED OPERATOR PHONE: (888) 500-2435 ext.2 El Service Technician Z Third-Party. <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: 8115508-UC EXPIRATION DATE: 5/27/2013 <br /> ALTERNATE 2 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(lfdifferentftoin above): F] owner F1 Operator Employee <br /> D-ESIGNATED OPERATOR PHONE: ( ) ext. El Service Technician Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> ALTERNATE 3 DESIGNATED UST OPERATOR FOR THIS FACILITY(Optional) <br /> DESIGNATED OPERATOR NAME: RELATION TO UST FACILITY(Check One) <br /> BUSINESS NAME(If differentftotn above): Owner 0 Operator El Employee <br /> DESIGNATED OPERATOR PHONE: ( ) ext. Service Technician Third-Party <br /> INTERNATIONAL CODE COUNCIL CERTIFICATION NO.: EXPIRATION DATE: <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST <br /> Operator(s). The individual(s) will conduct and document monthly facility inspections an g� <br /> in accordance with California Code of Regulations, Title 23,Section 2715(c)through (f). t 0 <br /> in compliance with the requirements(statutes,regulations,and local ordinances)applicableto un ground storage tams <br /> TANK OWNER NAME: ft 17 2012 <br /> TANK OWNER TITLE: OWNER PHONE `1 .°�,00 � <br /> TANK OWNER SIGNATURE: DATE: <br /> INSTRUCTIONS <br /> 1. Report the name(s)of the Designated UST Operator(s)as registered with the International Code Council (ICC). ICC certification <br /> information is available on-line at:www.iccsafe.org/e/certsearch.htmi. Search for"California UST System Operators." <br /> 2. Submit this completed form to the local agency that regulates this facility's USTs. Unidocs member agency jurisdictions and <br /> contact information are listed on-line at: www.unidoes.org/members/whoregulateswhat.htmi. Contact information for other <br /> local agencies within California is available at:www.swreb.ca.gov/cwphome/ust/contacts/does/local—agency_list.xls. <br /> 3. 23 CCR §2715(a)requires that you notify the local agency of any changes to this information within 30 days of the date of change. <br /> UN-062-1/1 www.unidoes.org 09/22/05 <br />