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APR 2 0 <br /> CUPA: San Joaquin County Environmental HealthE�IV1R( SIT HEALTH <br /> PERMITtSERVICES <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 4124 Facility ID#: #124 <br /> - <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: Copp,Gregory 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: 1/26/2012 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name. Alex Fast 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)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307848-UC Expiration Date: 3/14/2011 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone# (916)826-3200 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8025470-UC -Expiration Date: 2/2/2012 <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): Al,`/<i.:' RAAyk Lo 1, -P6 QwilZ 54e M,?/Oae:�z, _Lc. . <br /> SIGNATURE OF TANK OWNER: <br /> DATE: f-1 —1 5ZOI Q OWNER'S PHONE#: L's-1 -m vim— ZZ srs <br /> - - ---- --- - -- -i <br /> Page 1 <br />