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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: Mr. Cafe Facility ID#: <br /> Facility Address: 713 N. El Dorado Street Reason for Submitting this Form(Check One) <br /> Stockton, CA 95202 M Change of Designated Operator <br /> Facility Phone#: 408-807-9839 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Bruce N Stewart Relation to UST Facility(Check One) <br /> Business Name(lfdiiferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 55249892-UC Expiration Date: July 28, 2007 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Richard S Walton Relation to UST Facility(Check One) <br /> Business Name Qfdierentfrom above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-8255-3203 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 5243762-UC Expiration Date:October 12, 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): Fg4ocl �G <br /> SIGNATURE OF TANK OWNER: y1 <br /> DATE: (p��7�Q OWNER'S PHONE#: — � 3Q7�U <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 ag sem. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />