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CUPA: San Joaquin County Environmental Health lull I <br />Owner Statements of Designated Underground Storage Tank (UST) Operator 1 <br />and Understanding of and Compliance with UST Requirements W t <br />Facility Name: Quik Stop Market #124 <br />Facility ID #: # 124 <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician E Third -Party <br />Facility Address: 505 N. Main Sheet <br />Manteca, CA 95336 <br />Reason for Submitting this Form (Check One) <br />0 Update Certificate Expiration Date <br />International Code Council Certification #: <br />FacilityPhone #: 510-657-8500 <br />❑ Change of Designated Operator <br />Designated UST Operator(s) for this Facility <br />Designated Operator's Name: <br />Carpenter, Curtis <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician E Third -Party <br />Business Name (If different •oln above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-7857 <br />International Code Council Certification #: <br />8167865 -UC <br />Ex iration Date: 3/16/2017 <br />A T TP. DhT A TTi i <br />Designated Operator's Name: <br />William Culp <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician M Third -Party <br />Business Name Qfdifferenlftom above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-3065 <br />International Code Council Certification #: <br />8251286 <br />Expiration Date: 3/18/2016 <br />AT TPVDM A'PPi 7 //)s./inunll <br />Designated Operator's Name: <br />Harold Largo <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third -Party <br />Business Name (If di event from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 373-1888 <br />International Code Council Certification #: <br />8293993 <br />Expiration Date: 12/4/2016 <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): / Lo G! e-1-2- A <br />SIGNATURE OF TANK OWNER: (-S . <br />U 7 <br />Date: `� _ `� i Owner's Phone #: S $ �� <br />