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I * 0 0 RECENED <br />CUPA: San Joaquin County Environmental Health ° t 2_010 <br />q tY <br />Owner Statements of Designated Underground Storage Tan J% H <br />and Understanding of and Compliance with UST Requirements <br />i Facility Name: Bonfare Market # 35 <br />Facility Address: 15 W. Grant Line Road <br />Tracy, CA 95376 <br />1 Facility Phone #: — 209-833-9619 — <br />Designated UST Operator(s) <br />PRIMARY <br />Facility ID #: # 035 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator - <br />erator1Facility <br />■ Update Certificate Expiration Date <br />for this Facility <br />Designated Operator's Name: - <br />Copp, Gregory — <br />Relation to UST Facility (Check One) <br />Business Name (Ifdifferent from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone # <br />(916) 826-3082 <br />❑ Service Technician ■ Third -Party j <br />International Code Council Certification #: <br />5278409 -UC <br />Ex iration Date: 1/26/2012 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Alex Fast <br />Relation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />(Designated Operator's Phone #: <br />(916) 869-0023 <br />❑ Service Technician ■ Third -Party <br />-- _ <br />International Code Council Certification #: <br />5307848 -UC — <br />-_ ----- - — - - . it <br />Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name. <br />Mike Holkko <br />Relation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />1 ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: <br />(916) 826-3200 <br />❑ Service Technician ■ Third -Party <br />International Code Council Certification #: <br />8025470 -UC <br />Expiration Date: 2/2/2012 <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 Prim: <br />b A h 4 0, <br />SIGNATURE OF TANK OWNER: IV E <br />DATE: t' <br />OWNER'S PHONE #: q09Mr 111 <br />Page 1 <br />