COMPLIANCE INFO_2005-2009 - Laserfiche WebLink

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F-M - FIR CUPA: San Joaquin County*vironmental Health C Fo Owner Statements of Designated Underground Storage Tank (UST) OpeA& 1 4 2008 and Understanding of and Compliance with UST RequirementsFNVRONMENT HEALTH PERNI!T,/S E R V!C E S Facility Name: Bonfare Market#35 Facility ID #035 Facility Address: 15 W.Grant Line Road Reason for Submitting this Form(Check One) Tracy,CA 95376 o Change of Designated Operator Facility Phone#: 209-833-9619 m Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Greg Copp Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. 0 Owner 0 Operator 0 Employee Designated Operator's Phone#: (916)826-3082 0 Service Technician m Third-Party International Code Council Certification#: 5278409-UC Expiration Date: 1/29/2010 ALTERNATE 1(Optional) Designated Operator's Name: Darren Sciume Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. 0 Owner 0 Operator 0 Employee Designated Operator's Phone#: (916)825-3203 0 Service Technician m Third-Party International Code Council Certification#: 5261281-UC Expiration Date: 3/31/2009 ALTERNATE 2 (Optional) Designated Operator's Name: Michael Krull Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. 0 Owner El Operator 0 Employee Designated Operator's Phone#: (916)825-3203 El Service Technician m Third-Party International Code Council Certification#: 5307857-UC Expiration Date: 3/31/2009 1 certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations,title 23, section 2715(c) - (f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print). SIGNATURE OF TANK OWNER: YINDATE: OWNER'S PHONE#: NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa agys.htmi. 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004 Page I