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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: California Gas Station, LLC_ _ 'Reason <br />ID #; # 001 <br />Facility Address: 1399 E. Yosemite Ave. 'Reason for Submitting this Form (Check One) <br />Manteca, CA 95336 ❑ Change of Designated Operator <br />Facility Phone #: 209-551-1%2 _ _ I ■ Update Certificate Expiration Date J <br />PRIMARY <br />Name: <br />Designated UST Operator(s) for this Facility <br />(Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-6951 <br />rInternational Code Council Certification #: 8161927 -UC <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician w Third -Party <br />Expiration Date: 6/8/2014 <br />ALTERNATE l (Optional) <br />Designated Operator's Name: _ Ryan Powell Relation to UST Facility (Check One) <br />Business Name (ljdrfferent from above): Walton Engineering, Inc. _ J ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 869-0039 I ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: _ 5257345 -LIC 'Expiration Date: 3/14/2013 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Darren Sciume (Relation to UST Facility (Check One) <br />Business Name (/jdifferent from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 826-3138 ❑ Service Technician • Third -Party <br />International Code Council Certification #: 5261281-L'C iExpiration Date: 3/14/2013 <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): A- t Lk v l& <br />SIGNATURE OF TAN K OWNER: (',Q (y _a & f r <br />DATE: OWNER'S PHONE #:( <br />Page 1 <br />