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1 <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 /> ALTERNATE 3(Optional) <br /> Designated Operator's Name: Wadkins,Jessie —Relation to UST Facility(Check One) <br /> Business Name(1f different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)710-6235 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307886-UC Expiration Date: 5/4/2013 <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Chris Kuykendall 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)826-6951 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8161927-UC Expiration Date: 6/8/2014 <br /> ALTERNATE 5 (Optional) <br /> Designated Operator's Name: 0 Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 0 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 0 Expiration Date: 1/0/1900 <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): See page I <br /> SIGNATURE OF TANK OWNER: <br /> DATE: ON `tl I L OWNER'S PHONE#: k4 – d`( i 6 <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 /> AT: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 />