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r <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#148 Facility ID#: #148 <br /> Facility Address: 205 W.Lockeford Street Reason for Submitting this Form(Check One) <br /> Lodi,CA 95240 ■ 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: Ryan Powell 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)825-3203 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/31/2009 <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Alex Fast Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307848-UC Expiration Date: 3/24/2009 <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 /> 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): See pat=e 1 <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <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/cupa agvs.html. <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 />