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COPA: San Joaquin County Environmental Health APR 2 0 2010 <br /> Owner Statements of Designated Underground Storage TZ!qt <br /> OVIVW1 <br /> and Understanding of and Compliance with UST <br /> Facility Name: Quik Stop Market#76 Facility ID# #076 <br /> Facility Address: 1030 S.Olive Avenue Reason for Submitting this Form(Check One) <br /> — Stockton,CA 95215 ❑ Change of Designated Operator <br /> Facility Phone#: 910-657-8500 ■ 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 ElOperator ❑ Employee <br /> - -- <br /> Designated --- <br /> 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 Operators Phone# (916)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307848-UC Lxpiration Date:-- 3/14/2011 -� <br /> ALTERNATE 2 (Optional) <br /> Designate_d Operators Name Mike Holkko 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)826-3200 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8025470-UC 1Expiration 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): Xl< - A"Ar2d4:40 f, -A& Qw►(� Sl�Jp /✓t'R2lu:�s, INc <br /> SIGNATURE OF TANK OWNER: <br /> DATE: /S'Zd/O OWNER'S PHONE <br /> T <br /> Page 1 <br />