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JAN -09-2012 11:46 Service Station Systems <br />408 938 8888 P.02 <br />Facility Name: Shell <br />Faeilityl!)#- 136187 <br />Facility Addmav 2315 W- Grant Line Reason for Submitting this Form <br />ITy, CA 95376 19 Change of Designated Operator <br />Facility Phone: _(209) 836-8908 Update Certificate Expiration Date <br />Designated UST Operator($) for this Facility <br />Primary <br />Designated operator's Name: Bryan Lundien <br />Relation to UST F-iciliqC huck One) <br />Cl Owner 0 Operator ri Cmploylo <br />Business Name (If dIfferent ftm lbova): Service Station Systems <br />Designated Operator's Phone AFThird-pa <br />_ 971-2445 <br />jj� <br />la Service Technician j <br />International Code Council Codification #: 8001468 -UC <br />1------.. <br />Expiration Date: 8/16/13 <br />Alternate 1(Optional) <br />Damlgnated Oporatoes Name: Ryan Ca,%2L <br />Relation to UST Fweifiti(Check One) <br />Business Name (if r0farent frwn above): Service Station Systems <br />0 Owner 0 Operalor 11 Employee <br />M Service Technician 19 Third -Party <br />Qesignated Operators Phone P. J108) 971:2445 <br />Womatlonal Code Council Certification M 8057554 -UC <br />Expiration Date: 9/15/12 <br />Alternatei(Optionul) <br />Designated Opetalors Name., Dave Thomas <br />—gelann to UST FacilWCtieck One) <br />Cl Owner t.1 Operate( 13 Ernployee <br />M Service Technician 0 Third -Party III <br />Business Name (it 0feivol ftm above): Service Station Systems <br />Deftnated Operator's Phone �: (408) 971-2446 <br />International Code Council Cwtificatiovi * 5258666 -UC <br />Expiration Date: 712112 <br />lank —ow—ner <br />t certify that, for the facility indicated at the top of this page, the individual(s) listed above wilt serve as Designated <br />LIST 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 2716(u) - (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); --:10.4011 <br />0 � /� / - <br />Signature of Wk owner, / L -404a <br />Date:W- q0,9 PAVA-72S <br />Owner's Phone #; —f 7 <br />NOTE <br />1) 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, vAAiw,waterboards.ca.goviusttco.-itectstcupEk__agys.htmi. <br />2) Notify the Local Agency of any changes to this Information within 30 Days of the change. <br />TOTAL P.02 <br />