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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quik Stop Market Facility ID#: 132 <br /> Facility Address: 3555 W. Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton, CA 95219 M Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ❑ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Bruce N Stewart Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician N Third-Party <br /> International Code Council Certification#: 5249892-UC Expiration Date: July 28, 2007 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Richard S Walton Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 55243762-UC Expiration Date:October 12, 2006 <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): ik(= e4g p� d f oet „�� Sid ��/n� /c r. =Nc. <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 6—Z?- Q (o OWNER'S PHONE#: �S/d) 6 T 7- &/50 0 <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.izov/ust/contacts/cupa agvs.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />