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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 />ALTERNATE 3 (Optional) <br />Designated Operator's Name: Carpenter, Curtis 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) 825-7857 ❑ Service Technician 0 Third -Parry <br />International Code Council Certification #: 8167865 -UC Expiration Date: 3/20/2015 <br />ALTERNATE 4 (Optional) <br />Designated Operator's Name: Chris Kuykendall Relation to UST Facility (Check One) <br />Business Name (If different from above): Walton Engineering, Inc. j ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 826-6951 ❑ Service Technician 0 Third -Party <br />International Code Council Certification #: 8161927 -UC ;Expiration Date: 6/8/2014 <br />ALTERNATE 5 (Optional) <br />Designated Operator's Name Relation to UST Facility (Check One) <br />Business Name (If different from above): ❑ Owner ❑ Operator ❑ Employee <br />---- .- _-__. -_ - .—_ _ <br />Designated Operator's Phone #: ❑ Service Technician ❑ Third -Party <br />International Code Council Certification #: !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): <br />SIGNATURE OF TANK OWNER: -of. <br />DATE: 4-20-13 OWNER'S PHONE #: 510-657-8500 <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/cur)a act sy html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />Page 2 <br />