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CUPA: San Joaquin County nvironmental Health �' l C LC l rc:-� <br /> MAP, 7 2008 <br /> Owner Statements of Designated Underground Storage Tank VSTu0J;vW ffft5 <br /> and Understanding of and Compliance with UST Re � }� VICES <br /> Facility Name: Quik Stop Market#132 Facility ID#: #132 <br /> Facility Address: 3555 W.Hammer Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95219 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Desig=nated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Greg Copp 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)826-3082 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Date: 1/29/2010 <br /> ALTERNATE 1(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)825-3203 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date: 3/31/2009 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Michael Krull 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)825-3203 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307857-UC Expiration Date: 3/31/2009 <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): w``C �'Z`«271V <br /> SIGNATURE OF TANK OWNER: k <br /> DATE: — — OWNER'S PHONE#: _ (�®� 2 <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: .waterboards.ca.gov/ust/contacts/cupa aq sy htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> Page 1 <br />