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l9 <br />CUPA: San Joaquin County Environmental Health <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Designated UST Onerator(s) for this Facility <br />MAY 3 1 2007 <br />PRIMARY <br />Designated Operator's Name: Greg Copp Relation to UST F HEALTH <br />Business Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Ope a M��}g <br />Designated Operator's Phone #: (916) 826-3082 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC I Expiration Date: 2/16/2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Darren Sciume <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ 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 />5261281 -UC <br />Expiration Date: 3/31/2009 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Michael Krull <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ 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 />5307857 -UC <br />Expiration Date: 3/31/2009 <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): ��L� �A21/�'[. D ��� . e� �rJ✓. � A,A_r <br />SIGNATURE OF TANK OWNER: —�P' [ . 4, 0,;k E4, f A/ ,.. 374/C . <br />DATE: 5— Z 9 — 67 OWNER'S PHONE #: �sl 0� S-7' 8.5.6 0 <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 />Page 1 <br />