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• <br />8 2006 <br />Owner Statements of Designated Underground Storage Tank (UST) Operit&Ff,C'ijl v_j�=iw f hiE7AJH <br />and Understanding of and Compliance with UST Requirements PERP�'!'Z/��= <br />Facility Name: Nella Oil <br />Facility ID #: 487 <br />Facility Address: 983 Moffat Blvd. <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />S Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 530-885-0401 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Roger W Clark <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician V Third -Party <br />Business Name (Ifdiiferentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: <br />5256794 -UC <br />Expiration Date: July 21, 2007 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Gregory Copp <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician E■ Third -Party <br />Business Name (If differentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: <br />55278409 -UC <br />Expiration Date: February 16, 2008 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Lawrence M Lawrence <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician Q Third -Party <br />Business Name ( Ifdifferentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: 1048103 -UC <br />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): <br />SIGNATURE OF TANK OWNER: <br />DATE: I ) a(9 b10 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.pov/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 />