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REC EKED <br />•nvironmental Health • PR 2010 <br />cuPA: San Joaquin County E A 2 0 <br />Owner Statements of Designated Underground Storage TAl%W#"TAV;T N <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quik Stop Market #132 TFacility ID #: # 132 <br />Facility Address: 3555 W. Hammer Lane eason for Submittin this Form Check One <br />Stockton, CA 95219 ❑ n <br />Change of Designated Operator <br />- <br />g g_ P <br />Facility Phone #: 510-657-8500 L■ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification # <br />Copp, Gregory - <br />Walton Engineering, Inc. <br />(916)826-3082 <br />5278409 -UC <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Expiration Date. 1/26/2012 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Alex Fast <br />Relation to UST Facility (Check One) <br />- - <br />Name Qfdifferent from above): <br />— . _ _ - - <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />!Business <br />_ - <br />Designated Operator's Phone #_ <br />g P <br />(916 869-0023 <br />) <br />❑ Service Technician ■ Third -Party <br />_ <br />International Code Council Certification #: <br />--- <br />5307848 -UC <br />- _ <br />Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Mike Holkko <br />lRelation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />O p p Yee <br />� <br />Operator's Phone #: <br />(916) 826-3200 <br />❑ Service Technician ■ Third -Party <br />,Designated <br />International Code Council Certification #: <br />8025470 -UC <br />_jExpiration 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. /I <br />NAME OF TANK OWNER (Please Print): kK I1'gi j of �+2 �wi k Si w /✓ja&kL- <br />SIGNATURE OF TANK OWNER: <br />DATE: Z6I6 OWNER'S PHONE #: <br />Page 1 <br />