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1 0 J <br />CUPA: San Joaquin County Environmental Health 10 RECEIVED <br />Owner Statements of Designated Underground Storage Tank (UST) Ope&o 2013 <br />and Understanding of and Compliance with UST Requireme <br />Designated UST Operators) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Covan, Jeffrey <br />Relation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: <br />(916) 869-0023-0 <br />Service Technician 0 Third -Party <br />I <br />International Code Council Certification #: <br />8079216 -UC <br />;Expiration Date: 8/27/2014 <br />ALTERNATE 1 (Optional) <br />Designated _nt _._ <br />Powell - <br />Relation to UST Facility (Check One) <br />Business Name Ifdifferefrom above): <br />WYa° <br />WaltonEngineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: <br />(916) 869-0039 <br />❑ Service Technician 0 Third -Party <br />International Code Council Certification #: <br />5257345 -UC <br />Expiration Date: 3/1/2015 <br />ALTERNATE 2 (Optional) <br />gn p <br />n <br />Relation to UST Facility (Check One) <br />_ _ _ <br />Business Name (If different from above) • <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />(916) 826-3138 <br />5261281 <br />❑ Service Technician E Third -Party <br />-UC - <br />; Expiration Date: 3/1/2015 <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: -o <br />DATE: 4-20-13 OWNER'S PHONE #: 510-657-8500 <br />Page 1 <br />