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DEC 3 0 2004 <br /> Owner Statements of Designated Underground Storagt=,FT,Ank\(UST)„Operator <br /> and Understanding of Compliance with UST R&4Ujf6meli'fs 1_ <br /> Facility Name: SHELL- 136139 Facility ID#: 136139 <br /> Facility Address: 7910 LOWER SACRAMENTO RD Reason for Submitting this Form(Check One) <br /> STOCKTON,CA X Change of Designated Operator <br /> Facility Phone#:209.472-7748 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name:James Cusick Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:916-601-9337 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:unavailable,passing report attached Expiration Date:not applicable <br /> ALTERNATE 1 fflptiLonaq <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 /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:David Resnick Relation to UST Facility(Check One) <br /> Business Name(Ifdierent from above):Delta Environmental Consultants,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:925-743-1429 ❑ Service Technician X Third-Party <br /> International Code Council Certification#:unavailable,passing report attached Expiration Date:not applicable <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) <br /> SIGNATURE OF TANK OWNER:14m. <br /> 61,1 V <br /> / ^�/ <br /> DATE: OWNER'S PHONE#: 91� o2Ve--1!010 <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.izov/ust/contacts/coa 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 />