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0 9 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Stockton Terminal Facility ID#: <br /> Facility Address: 3515 Navy Dr. Reason for Submitting this Form(Check One) <br /> Stockton,CA 95203 Cl Change of Designated Operator <br /> Facility Phone#: 209.466.6941 ® Update Certificate Expiration Date <br /> Desi nested UST Q erator s for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George Koffei Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner O Operator a Employee <br /> Designated Operator's Phone#: 714.920.5387 O Service Technician m Third-Party <br /> lntemational Code Council Certification#: 5247982-UC Expiration Date: 12f19f2008 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Tait Environmental Relation to UST Facility(Check One) <br /> Business Name(If different from above): See Attached p Owner Q Operator O Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certi&cation#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): Q Owner 0 Operator O Employee <br /> Designated Operator's Phone if: ❑ Service Technician 0 Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> 1 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)-(fl. <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: <br /> DATE: 1122107 OWNER'S PHONE#: <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.gov/usticontacts/cupa a s.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />