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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 <br />Facility ID #: 125 <br />Facility Address: 1580 W. Main Street <br />Ripon, CA 95366 <br />Reason for Submitting this Form (Check One) <br />M Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 510-657-8500 <br />Designated UST Oaerator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE I (Optional) <br />Designated Operator's Name: Bruce N Stewart <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑■ Third -Parry <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: 5249892 -UC <br />Expiration Date: July 28, 2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Richard S Walton <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑■ Third -Party <br />Business Name (If diiferentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: <br />55243762 -UC <br />Expiration Date: October 12, 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 <br />SIGNATURE OF TANK OWNER: <br />DATE: 46 — 2 E—e) (p OWNER'S PHONE #: (Ll4) 6-:57— S SO0 <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.yov/ust/contacts/cupaa aeys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />