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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: Marigold Shell Facility ID#: SA0002324 <br /> Facility Address: 6131 Pacific Avenue Reason for Submitting this Form (Check One) <br /> Stockton, CA 95207 K Change of Designated Operator <br /> Facility Phone#: 209-952-4862 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Kathy Kotulak Relation to UST Facility(Check One) <br /> Business Name(If different from above): Hemmen Consulting ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: 925-413-7422 ❑Service Technician Third-Party <br /> International Code Council Certification#: 5240722-UC Expiration Date: 8/12/2006 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: ❑Service Technician ❑Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone#: ❑Service Technician ❑Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 _ <br /> OR OWNER'S AGENT(Please Print): Z-// <br /> SIGNATURE OF TANK <br /> OWNER OR OWNER'S AGENT: 4,1'( <br /> DATE: l� — f—�OWNER'S PHONE#: 209-473-8205 <br />