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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Stockton Shell Terminal Facility ID#: <br /> Facility Address: 3,515 Navy Drive Reason for Submitting this Form(Check One) <br /> Stockton,CA 95203 0 Change of Designated Operator <br /> Facility Phone#: (209)466-6941 17 Update Certificate Expiration Date <br /> Desi nated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George Koffel Relation to UST Facility(Check One) <br /> Business Name(If di f'erenl from above): 0 Owner ❑ Operator 13 Employee <br /> Designated Operator's Phone#: 714.560.8200 0 Service Technician 0 Third-Party <br /> International Code Council Certification#: 5247982-UG Expiration Date: 12123106 <br /> ALTERNATE Z O trona <br /> Designated Operator's Name: Tait Environmental Systems Relation to UST Facility(Check One) <br /> Business Name(Ifdifferenr from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.560.8200 ❑ Service Technician 0 Third-Party <br /> lnternationai Code Council Certification#: See Attached Expiration Date: See Attached <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(IfdIerent from above): ❑ Owner El Operator ❑ Employee <br /> Designated Operator's Phone#: 0 Service Technician © Third-Party <br /> International Code Council Certification#: Expiration Date: <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): a2 C <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 1 �/ l� _ 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/ust/contacts/cu 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 />