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it # <br /> RECYE <br /> CUPA: San Joaquin CountyOnvironmental Health <br /> Owner Statements of Designated Underground Storage Tank (UST) (J Mt&7-009 <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quik Stop Market#132 Facility ID#: #12� <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 /> DesiEnated UST Overator(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: Alex Fast 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)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307848-UC Expiration Date: 3/14/2011 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Ryan Powell 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)826-3084 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/28/2011 <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): /,q,1<*, /46V_ -LCT• Let Q -; < S4.4 ALL, 1-'Vc . <br /> SIGNATURE OF TANK OWNER: ------L�-1 �� <br /> DATE: A 133 - 6 OWNER'S PHONE#: S00 - Al 1/S- 2 Z$.5- <br /> Page <br /> Page 1 <br />