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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: Pac Bell dba AT&T California Facility ID#: TRACCAII <br /> Facility Address: 10 E. 12Th Street Reason for Submitting this Form(Check One) <br /> Tracy ❑ Change of Designated Operator <br /> Facility Phone#: (209)943-4128 ® Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: George Koffel Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): Tait Environmental Services ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.560.8200 ❑ Service Technician m Third-Party <br /> International Code Council Certification#: 5247982-UC Expiration Date: 12/19/2008 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Tait Environmental Services Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 714.560.8200 ❑ Service Technician ® Third-Party <br /> International 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(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ 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): Julie Khdryan <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 12/18/2006 OW ER'S PH E#: 214-464-2599 <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.cov/ust/contacts/cupa 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 />