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j <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: 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#: ■ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Covan,Jeffrey 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)869-0023 ❑ Service Technician ■ Third-Party <br /> (International Code Council Certification#: 8079216-UC (Expiration Date: 8/27/2014 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. El Owner ❑ Operator C1 Employee <br /> Designated Operator's Phone#: (916)869-0039 ❑ Service Technician ■ Third-Party <br /> [International Code Council Certification#: 5257345-UC 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(Ifdifferentfrom above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 1❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration 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): VAY, N_: P�� C V-�c I tyC_ ; <br /> - <br /> SIGNATURE OF TANK OWNER: •---- <br /> DATE: C,\1OWNER'S PHONE#: )-e)c ci v-( -Ct 11-5 <br /> Page 1 <br />