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Owner Statements of Designated Underground Storage Tank ( pgllat4 9: 0 <br /> and Understanding of and Compliance with UST RequlreAA <br /> 7-1111 ,r <br /> Facility Name: Mr. Cafe Facility ID#: E N�'I h C;u 1'!E N T A <br /> Facility Address: 713 N. EI Dorado Street Reason for Submi t 'j t TM�P I T <br /> Stockton, CA 95202 ■ Change of Designated Operator <br /> Facility Phone#: 408-807-9839 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: Gregory Copp Relation to UST Facility(Check One) <br /> Business Name Qfdifferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-8255-3203 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Date: February 16, 2008 <br /> ALTERNATE 1 O tional <br /> Designated Operator's Name: Roger W Clark Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician E Third-Party <br /> International Code Council Certification#: 5256794-UC Expiration Date: July 21, 2007 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Lawrence M Lawrence Relation to UST Facility(Check One) <br /> Business Name(If dii ferentfrom above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician © Third-Party <br /> International Code Council Certification#: 1048103-UC Expiration Date:October 14, 2006 <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): is <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 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/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 />