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ft 0 tA <br />CUPA: San Joaquin Coun nvironmental Health <br />9 tY <br />SEP 10 20-12, <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <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: <br />Covan, Jefffrey <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 869-0023 <br />International Code Council Certification #: <br />8079216 -UC <br />Expiration 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. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operators Phone #: (916) 869-0039 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #_ 5257345 -UC Expiration Date: 3/14/2013 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Darren Sciume <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-3138 <br />International Code Council Certification #: <br />5261281 -UC <br />Expiration Date: 3/14/2013 <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): Michael Karvelot <br />SIGNATURE OF TANK OWNER: -ev <br />DATE: 9-1-27 OWNER'S PHONE #: 510-657-8500 <br />Page 1 <br />