Laserfiche WebLink
CUPA: San Joaquin County*rnvironmental Health 10 RECEIVED <br /> Owner Statements of Designated Underground Storage Tank (UST) OaO 20113 4ft <br /> and Understanding of and Compliance with UST RequirenLentqj RONMENTAL <br /> — 1 .­____HEA-L141 DEPARTMENT <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 o Change of Designated Operator <br /> - <br /> Facility[ Phone 510-657-8500 El Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Covan,Jeffrey Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. 0 Owner El Operator 0 Employee <br /> Designated Operator's Phone#: (916)869-0023 0 Service Technician 0 Third-Party <br /> [International Code Council Certification#: 8079216-UCExpiration Date: 8/27/2014 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> ,Business Name(If different from above): Walton Engineering,Inc. 0 Owner El Operator El Employee <br /> Designated Operator's L Phone#-. (916)869-0039 _0-service Technician N Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/1/2015 <br /> ALTERNATE 2 (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 0 Operator 0 Employee <br /> [Designated Operator's Phone#: (916)826-3138 0 Service Technician 0 Third-Party <br /> Llntemational Code Council Certification 4: 5261281-UC Expiration Date: 3/1/2015 <br /> 1 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): Michael Karvelot <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 4-20-13 OWNER'S PHONE 510-657-8500 <br /> Page 1 <br />