Laserfiche WebLink
cuPa: San Joaquin County L�'nvironmental Health <br /> MA„ 7 2008 <br /> Owner Statements of Designated Underground Std3T`Q,5=1nts 8! Dperator <br /> and Understandingof and Compliance with <br /> p <br /> Facility Name: Quik Stop Market#124 Facility ID#: #124 <br /> Facility Address: 505 N.Main Street Reason for Submitting this Form(Check One) <br /> Manteca,CA 95336 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated 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): <br /> SIGNATURE OF TANK OWNER: rZ ",; 1< Slt Ala z/ e4f -ToC . <br /> DATE: 3 —`�— Q�S OWNER'S PHONE#: <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.gov/ust/contacts/cupa agys.html. <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 />