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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facilit Name: California Gas Station, LLC _ Facility 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 #: 209-551-1962 _ ❑ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />ALTERNATE 3 (Optional) <br />;Designated Operator's Name: Miranda, Mauricio 'Relation to UST Facility (Check One) <br />Business Name (Ijdii ereni from above)_ Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 826-6467_ _ _ 10 Service Technician in Third Pany <br />International Code Council Certification #: 5252100 -UC ,Expiration Date: 6/8/2013 <br />ALTERNATE 4 (Optional) <br />Designated Operator's Name: Jessie Wadkins Relation to UST Facility (Check One) <br />Business Name (IjdiJjerent from above) Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 710-6235 _ _ ❑ Service Technician is Third -Party <br />International Code Council Certification #: <br />ALTERNATE 5 (Optional) <br />5307886 -UC <br />Expiration Date: 5/4/2013 <br />Designated Operator's Name: <br />JefCovan <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />_ <br />Business Name (If dii(%rent from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 869-0023 <br />International Code Council Certification #: <br />8079216 -UC <br />Expiration Date: 9/1/2012 <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 />I <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 page I <br />SIGNATURE OF TANK OWNER: <br />DATE: <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 />A I': www,waterboards.ca.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />Page 2 <br />