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Owner Statements of Designated Underground Storage <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quik Stop Market Facility ID#: 132 <br /> Facility Address: 3555 W. Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton, CA 95219 M Change of Designated Operator <br /> Facility Phone#: 510-657-8500 0 Update Certificate Expiration Date <br /> Designated UST Overator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Roger W Clark Relation to UST Facility(Check One) <br /> Business Name(Idifferenlfrom above): Walton Engineering, Inc. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 916-825-3203 El Service Technician M Third-Party <br /> International Code Council Certification#: 5256794-UC Expiration Date: July 21, 2007 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Gregory Copp Relation to UST Facility(Check One) <br /> Business Name(Idifferentftom above): Walton Engineering, Inc. 0 Owner [I Operator 11 Employee <br /> Designated Operator's Phone#: 916-825-3203 El Service Technician N 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(Idifferentftom above): Walton Engineering, Inc.. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 916-825-3203 0 Service Technician M Third-Party <br /> International Code Council Certification#: 1048103-UC Expiration Date: October 14, 2006 <br /> 1 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/ <br /> o underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): &A�C 1-64AVA40 f Att Q­,*A� V134 flf1'44_,, —TVG- <br /> SIGNATURE OF TANK OWNER: <br /> DATE:— OWNER'S PHONE#: L61 Oj S7- F`S'0 0 <br /> %I I <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.jzov/ust/contacts/cupa aizys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />