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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. Quik Stop Market#124 jFacility ID#: # 124 i <br /> Facility Address: 505 N.Main Street Reason for Submitting this Form(Check One) <br /> Manteca CA 95336 1■ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> ALTERNATE 3(Optional) _ <br /> Designated Operators Name: - Sciume Darren J Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. I❑ Owner ❑ Operator ❑ Employee <br /> i <br /> Designated Operator's Ph—one# (916)826-3138 Ti❑ Service Technician ■ Third-Party <br /> ----__ <br /> International Code Council Certification#: 5261281-UC Expiration Date: 3/27/2011 <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> �Busmess Name(If different from above) Walton Engineering,Inc ❑ Owner ElOperator ❑ Employee <br /> (Designated Operator's Phone#: (916)826-3084 -- El Technician ■ Third Party <br /> --- -- — --- — - -- - <br /> International Code Council Certification#: 5257345-UC Expiration Date 3/28/2011 <br /> ALTERNATE 5 (Optional) <br /> __- -- -- — --- --- <br /> Designated Operators Name: Jessie Wadkms J 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)710-6235 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307886-UC Expiration Date 5/16/2011 <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 /> SIGNATURE OF TANK OWNER: <br /> i <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.htmi. <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 />