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Owner Statements of Designated Underground Storage Tank (UST) <br />Operator and Understanding of and Compliance with UST requirements <br />Facility Name: SHELL SITE# 136186 <br />Facility ID #: 104264 <br />Facility Address: 3725 TRACY BLVD <br />TRACY, CA 95376 <br />Reason for Submitting this Form (Check One) <br />❑x Change of Designated Operator <br />❑ Update ICC # and/or Expiration Date <br />Facility Phone #: 209-835-7608 <br />Designated UST Operators) for this Facility <br />Primary Optional) <br />Designated Operator's Name: Kevin Watermolen <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑D Third -Party <br />Business Name (If different from above): Gilbarco Veeder-Root <br />Designated Operator's Phone #: 916-838-6749 <br />International Code Council Certification #: 5250470 -UC <br />Expiration Date: 9/2/2010 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: SEE ATTACHED LIST <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician [K Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: SEE ATTACHED LIST <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑x Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed <br />above will serve as Designated UST Operator(s). The individual(s) will conduct and <br />document monthly facility inspections and annual facility employee training, in <br />accordance with California Code of 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): Shell Oil Products US c/o Gilbarco Veeder-Root — <br />Michel Sutton <br />SIGNATURE OF TANK OWNER: <br />DATE: 1/26/2009 OWNER'S PHONE #: 336-315-2895 <br />November 2004 <br />