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CUPA: San Joaquin County Environmental Health, , — U , , " V, <br />. n <br />Owner Statements of Designated Underground Storage Tank (UST) Operator I,' <br />and Understanding of and Compliance with UST Requirements <br />18 <br />Facility Name: Quik Stop Market #124 Facility ID #: # �� � u �' i 1 i <br />Facility Address: 505 N. Main Street Reason for Submitting this Form (Check One) <br />Manteca, CA 95336 0 Update Certificate Expiration Date <br />Facilitv Phone #: 510-657-8500 ❑ Change of Designated Operator <br />Designated UST Operator(s) for this Facili <br />Designated Operator's Name: <br />Carpenter, Curtis <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician 0 Third-Paty <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-7857 <br />International Code Council Certification #: <br />8167865 -UC <br />Expiration Date: 3/16/2017 „ <br />. T TTi T? iV A TT'i 1 /nnlinnnll <br />Designated Operator's Name: William Culp Relation to UST Facility (Check One) <br />3usiness Name (I di erent from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: 916) 826-3065 ❑ Service Technician 0 Third -Party <br />International Code Council Certification #: 8251286 Expiration Date: 3/18/2016 <br />Designated Operator's Name: Harold Largo 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) 373-1888 ~ ❑ Service Technician 0 Third -Party <br />International Code Council Certification #: 8293993 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 />j <br />NAME OF TANK OWNER (Please Print): t ` O Gi clZ /--- <br />SIGNATURE OF TANK OWNER: <br />Date: <br />S �� / Owner's Phone <br />