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i <br />,;i j+.. 'J ; �"J05 <br />Owner Statements of Designated Underground Storage Tank (US.T i)�Operator ",,,, i i; <br />and Understanding of and Compliance with UST Requiret4ts <br />Facility Name: Quik Stop Market <br />Facility ID #: 121 <br />Facility Address: 1196 W. Louise Avenue <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />® Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 510-657-8500 <br />Designated UST Operators) 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 ❑■ Third -Party <br />Business Name (If diiferentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-825-3203 <br />International Code Council Certification #: <br />5256794 -UC <br />Expiration Date: July 21, 2007 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Gregory Copp <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (If differentfrom above): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-825-3203 <br />International Code Council Certification #: 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 M Third -Party <br />Business Name (If differentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-825-3203 <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 27I5(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable tounderground storage tanks. <br />NAME OF TANK OWNER (Please Print): IV' -A42� /t/AfQ 1/,15L0 f 4R Qom, k &h j* NR T•, rNc. <br />SIGNATURE OF TANK OWNER: <br />DATE: OWNER'S PHONE #: k10 ( S %- FiS0 0 <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/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 />