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0 0 fiE-nCZVE0p <br /> CUPA: San Joaquin County Environmental Health 1010 <br /> APR 2 4 <br /> Owner Statements of Designated Underground Storage Tank (USimmww HEALTH. <br /> and Understanding of and Compliance with UST RequiremenKRMIT>SERVICES <br /> Facility Name: Quik Stop Market#144 Facility ID#: — —#144 <br /> Facility Address: 7272 West Lane Reason for Submitting this Form(Check One) <br /> Stockton,CA 95210 ❑ 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(Ifdifferentfrom above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> International�Design ed Operator's Phone#: (916) 82 Technician Third-Party <br /> Code Council I Certification#: 5278409-UCExpiration ation Date 1/26/2012 —J <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 O Operator ❑ Employee <br /> Designated Operator's 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): /%"/<L= k4AVC10� - 2 0";k IgArzkt?Ts_ 10C. - <br /> SIGNATURE <br /> 0C. .SIGNATURE OF TANK OWNER: <br /> I <br /> DATE: /.5.— 20/0 OWNER'S PHONE#: (Sl4J y`f s- ZZSS <br /> Page 1 <br />