Laserfiche WebLink
Received: Jun 5 2007 11:06am <br /> 06/05/2007 11:58 916-37372 WALTON ENGINEERS PAGE 02 <br /> CUPA: San Joaquin County Environmental Health <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Raley's#356 Facility ID 4: #006 <br /> Facility Address: 4219 Morada Lane Reason for Submitting this Form(Check One) <br /> _ Stockton,CA 95212 ■ Change of Designated O_pecator <br /> Facility Phone#: 209-956-9300_ ❑ Update Certificate Expiration Dcte <br /> Designated UST Operstor(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Names Greg Co Relation to UST Facility(Check One) <br /> Business Name(.{fdii erenlfrnm above): Walton Engineering,Ino. ❑ Owner ❑ Operator ❑ Employee <br /> Designated OperaWr's Phone#: (916)826-3082 ❑ Service Technician w Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Daze: 2/16/2008 <br /> ALTERNATE 1(Optional) _ <br /> Designated Operator's Name: D■rrea Schtme Relation to UST Facility(Check One) <br /> Business Name(ydiacrit from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employec <br /> Designated Operator's Phone#: _ _ (916)825-3203 ❑ Service Technician ai Third-Party <br /> international Code Council Certification#: 5261281-UC Expiration Due: 3/31,/2009 <br /> ALTERNATE 2 (Optional) <br /> Designated_Operator's Name: Michael Krull Relaaon to UST Facility(Check One) <br /> Business Name(Ifdifferenr from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)825-3203 ❑ Service Technician ■ Tblyd-Party <br /> Intemational Code Council Certification#: 5307857-UC Expiration Date: 3/31/2009 <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: rr ll / k <br /> DATE: hr-S- O S PHONE#:1�Q <br /> NOTE: 1)SUBMIT TATS 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,govlust/contacts/cupa agys.html. <br /> 2)NOTIFY TAE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Page 1 <br />