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:IA <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quik Stop Market#144 Facility ID#: #144 <br /> Facility Address: 7272 West Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95210 ■ 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 Operator's Name. Sciume,Darren 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)826-3138 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date. 3/27/2011 J <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Ryan Powell 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)826-3084 ❑ Service Technician ■ Third-Party <br /> International Code CouncilCertification#: 5257345-UC iExpiration Date: 3/28/2011 <br /> ALTERNATE 5 (Optional) <br /> -_--------- <br /> ,,Designated nated O e(� Name Jessie Wadkins - Relation to UST Facility(Check One) <br /> ;Business Name 1di ferent rom above): Walton Engineering,Inc. ❑ Owner ❑ Operator El Employee I <br /> ,Designated Operator's Phone#: (916)710-6235 ❑ Service Technician ■ Third-Party <br /> LIntemational 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): Seepage--1_ <br /> i <br /> j SIGNATURE OF TANK OWNER: <br /> i <br /> DATE: OWNER'S PHONE#: <br /> i <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 />