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JON-09-2012 09:57 SeAmbiLce Station Systems 408 938 8888 P.02 <br /> PF 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Tracy Blvd Shell&Mini MartFadlity ID It: 13,6186 <br /> FacilityAddrass- 3725 N.Traqy Blvd, ReCkSOA for Submitting this Form <br /> CA 95376 &1 change of Designatea ODetor <br /> FOCAY Phonez (209)835-7608 01 Update cartiricate 6*ration Cate <br /> Designated UST Operators)for this Facility <br /> Primary <br /> Designated Operators Name: jryan Lundlen m. Relation to UST FaaiV0I)evk One) <br /> Bu!jinew Name(If(Vftbmr#from above): Service Station$yStOMS 11 Owner 0 Operator 0 FroployeD <br /> (Designated Operator's Phone Ok. ___.jjC@jj71-2j45 3 Service Technician El Third-Party <br /> lntefna.'ional Code CouncH Gertifrr alien 8001468-UC kxpiratkm Crate 8/16/13 <br /> Alternate i(Opffanal) <br /> Designated operator's Name,. Ryan Casey Relation to VST FaciliqCheck one) <br /> Business Name(1f diffewt frorn above): Service Station Systems 0 Owner o Operator a Emptoyee <br /> Designated Operator's Phone#r (408)971-7445 0 Service Technician C3 Third-Party <br /> International Code Couni;i[Certification 4; 805755+UC' <br /> Eaeplration trate: /15112 <br /> [A Alternate 2(Optional) <br /> Designated <br /> esignated Operator`9 Name: Dave Thomas Relation to UST FaciliVGheCk One) <br /> U <br /> Businew Name ff diffempt from above); Service Station SystemEl s 0 Owner Operator 0 Employee <br /> Designated operator's Phone M (408)971-2445 2 Service Technician J2 Thiro-Party <br /> Intematiotial Cod*Council Ceitification$11' 5258566-UC Expiration Date- 7/211 <br /> -Tank owner <br /> r—,C—L-�ify—that, for the facility indicated at the top of this page, the individu31(s) listed above will serve as Designated <br /> UST Operator(s). The individuat(s)will conduct and document monthly facility inspections and annual facility <br /> employee training, in accordance with California Code of Regulations, titte 23, section 2715(c) -(f). <br /> Furthermore,I understand and urn in compliance with the requirements(statutes, regulations, and local <br /> ordinances)applicable to underground storage tanks. <br /> Name of tank owner(Please Print): —<7n <br /> Signature of tank owner. A-z4- <br /> F IV a C/ <br /> Date., Z—/a 4z Owner's Phone#: <br /> NOTE., <br /> 11 Submit this completed form to the Local Agency(NOT the State Water Resources Control Board) <br /> By January 1,2005-The local agency list is available at: www.wFiterboirds,co.govlustiqonl8f±-,ICLIPa_FJgys.htrnl. <br /> 2) Notify the Local Agency of any changes to this information within 30 Days of the change. <br /> TOTAL P.02 <br />