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C <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quik Stop Market #124 <br />Facility ID #: # 124 <br />Facility Address: 505 N. Main Street <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />m Change of Designated Operator <br />Facility Phone #: 510-657-8500 <br />❑ Update Certificate Expiration Date <br />Designated UST Oaerator(s) for this Facility <br />ALTERNATE 3 (Oodonal) <br />Designated Operator's Name: <br />Ryan Powell <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician m Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-3203 <br />International Code Council Certification #: <br />5257345 -UC <br />I Expiration Date: 3/31/2009 <br />ALTERNATE 4 (Optional) <br />Designated Operator's Name: Alex Fast Relation to UST Facility (Check One) <br />Business Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 869-0023 ❑ Service Technician m Third -Party <br />International Code Council Certification #: 5307848 -UC Expiration Date: 3/24/2009 <br />ALTERNATE 5 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />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): See page 1 <br />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: .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 />Page 2 <br />