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REGL_­. L <br /> CUPA: San Joaquin County Environmental Health r <br /> Owner Statements of Designated Underground Storage Tank (UST -o : NTA <br /> and Understanding of and Compliance with UST Requirement EAL i H DEPS.,4 i} <br /> Facility Name: Ramos Oil#4376 Facility ID#: #017 <br /> Facility Address: 10842 S.Harlan Road Reason for Submitting this Form(Check One) <br /> French Camp,CA 95231 ❑ Change of Designated Operator <br /> Facility Phone#: 800-477-7266 x 244 ■ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY ll <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. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)869-0039 ❑ Service Technician ■ Third-Party <br /> [International Code Council Certification#: 5257345-UC — Expiration Date: 3/1/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Darren Sciume 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)826-3138 ❑ Service Technician Ill Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date: 3/1/2015 <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): Dave Nelson <br /> SIGNATURE OF TANK OWNE <br /> DATE: 7-31-13 OWNER'S PHONE#: 00-477-7266 <br /> Page 1 <br />