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Owner Statements of Designated Underground Storage Tank (UST) <br /> Operator and Understanding of and Compliance with UST requirements <br /> Facility Name: SHELL SITE#136187 Facility ID#: 104307 <br /> Facility Address: 2375 WEST GRANT LINE ROAD Reason for Submitting this Form(Check One) <br /> TRACY,CA 95376 ❑x Change of Designated Operator <br /> Facility Phone#: 209-836-8908 ❑ Update ICC#and/or Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> Prima (Optional) <br /> Designated Operator's Name: Christine Harris Relation to UST Facility(Check One) <br /> Business Name(If different from above):Gilbarco Veeder-Root ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 925-206-5455 ❑ Service Technician ❑x Third-Party <br /> International Code Council Certification#: 5319944-UC Expiration Date: 9/27/2009 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician IE Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 2(Optional) <br /> Designated Operator's Name: SEE ATTACHED LIST Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑O 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 <br /> above will serve as Designated UST Operator(s). The individual(s) will conduct and <br /> document monthly facility inspections and annual facility employee training, in <br /> accordance with California Code of 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): Shell Oil Products US c/o Gilbarco Veeder-Root— <br /> Michael Sutton <br /> SIGNATURE OF TANK OWNER: 4eK,Zr� <br /> DATE: 3/11/2008 OWNER'S PHONE#: 336-315-2895 <br /> November 2004 <br />