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vironmental Health <br /> CUPA: San Joaquin County ..n <br /> Owner Statements of Designated Underground Storage Tank (UST) &Akiwoog <br /> and Understanding of and Compliance with UST Requirem&RSO (� T-Y <br /> EN'VjQL'�'�).'OUN <br /> HE.4ri M."l—l"ENTAL <br /> Facility Name: Quik Stop Market$0 76 Facility ID#: #076 - ­- TMENT <br /> Facility Address: 1030 S.Olive Avenue Reason for Submitting this Form(Check One) <br /> Stockton,CA 95215 o Change of Designated Operator <br /> Facility Phone 4: 510-657-8500 m Update Certificate Expiration Date <br /> Desianated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Greg Copp Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: (916)826-3082 F-1 Service Technician m Third-Party <br /> International Code Council Certification 5278409-UC Expiration Date: 1/29/2010 <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. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: (916)869-0023oService Technician m Third-Party <br /> International Code Council Certification#: 5307848-UC Expiration Date: 3/14/2011 <br /> ALTERNATE 2 (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 0 Operator 0 Employee <br /> Designated Operator's Phone#: (916)826-3084 0 Service Technician m Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/28/2011 <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): k,9481Ax--�d <br /> SIGNATURE OF TANK OWNER: __1A117 <br /> DATE: /17 - D q OWNER'S PHONE#: S1 Lj- Al YS- 2-'?- <br /> Page I <br />