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'-D'ECOVED <br />in <br />SEP 1 7 2007 <br />ENVIRONMENT HEALTH <br />Owner Statements of Designated Underground Storage Tank (UST) U#yffV6fRVICES <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quick Stuff # 7789 <br />Facility ID #: 7789 <br />Facility Address: 10858 Trinity Parkway <br />Stockton CA 95210 <br />Reason for Submitting this Form (Check One) <br />El Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: (209) 952-2213 <br />Desianated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Jesse Kirk <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />17 Service Technician ❑ Third -Party <br />Business Name (If different from above): MIT Engineering <br />Designated Operator's Phone #: (760) 889-3115 <br />International Code Council Certification #:1036149 -UC <br />Expiration Date: 12/15/08 <br />ALTERNATE I (Optional) <br />Designated Operator's Name: Paul Vidakovich <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />El Service Technician ❑ Third -Party <br />Business Name (If different from above): MIT Engineering <br />Designated Operator's Phone #: (760) 721-4120 <br />International Code Council Certification #: 5285966 -UC <br />Expiration Date: 6/9/08 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Josh Barrera <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />Service Technician ❑ Third -Party <br />Business Name (If different from above): MIT Engineering <br />Designated Operator's Phone #: (760) 721-4120 <br />International Code Council Certification #: 5297792 -UC <br />Expiration Date: 1/5/09 <br />NOTE: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO THIS <br />INFORMATION WITHIN 30 DAYS OF THE CHANGE. <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 <br />OR OWNER'S AGENT (Please Print): Daniel A Erickson <br />SIGNATURE OF TANK <br />OWNER OR OWNER'S AGENT: <br />-Da <br />DATE: 9/11/07 OWNER'S PHONE #: (847) 888-0276 <br />September 2004 <br />