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Received: Jun 5 2007 11:06am <br /> 06/05/2007 11:58 916-3772 WALTON ENGINEER PAGE 03 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of. and Compliance with UST Requirements <br /> Facly Name: Raloy's#366 Facility ID(!; $008 <br /> Facility Address: 4219 Morads Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95212 ■ ChanLee of Designated Operator <br /> Facility Phone#: 209-956-9300 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> ALTERNATE 3(Optional) <br /> r <br /> igaated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> iness Name(If differeru from above): Walton Engiaeeriog.Inc. ❑ Owner ❑ Operator ❑ Employee <br /> ignated Operator's Phone#; (916)825-3203 ❑ Service Technician a Third-Fury <br /> metional Code Council Certification#: . 525'7345•UC E iration Date: _ 3/31/MW <br /> ALTERNATE 4(Opdoaal) _ <br /> Designated rotor's Name: Alex Fast v-� Relation to UST Facility(Check One) <br /> Basiness Name Qfdierenrfrom above): , Walton Engineering,be. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)669-0023 ❑ Service Technician n Third-Patty <br /> International Code Council Certification#: 5307848-UC Ex iration Date: 3/24!2009 <br /> ALTERNATE 5 (Optional) <br /> Designated Opaator's Namc: Relation to UST Facility(Cheek One) <br /> Business Name(Ifdifferentfrom above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: _ ❑ Service Technician to Third-Party <br /> international Code Council Certification E irationDatc: <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 individuals)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 oaRe 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.TAE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ce.gov/ustJcontactalcupa aays.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS BVFORIVATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Page 2 <br />