Laserfiche WebLink
A <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: N@Ila Oil Facility ID#: 427 <br /> Facility Address: 3300 Waterloo Road Reason for Submitting this Form(Check One) <br /> Stockton, CA 95205 ll! Change of Designated Operator <br /> Facility Phone#: 530-885-0401 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Roger W Clark Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: 5256794-UC Expiration Date: July 21, 2007 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Gregory Copp Relation to UST Facility(Check One) <br /> Business Name(If dfferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician X Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Date: February 16, 2008 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Lawrence M Lawrence Relation to UST Facility(Check One) <br /> Business Name(If dfferentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-8255-3203 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 1048103-UC Expiration Date: October 14, 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): Y1rt�I <br /> SIGNATURE OF TANK OWNER: i <br /> DATE: ���,� � OWNER'S PHONE <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.eov/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 /> November 2004 <br />