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1% 4 0 RECENLA) <br /> CUPA: San Joaquin Countynvironmental Health MAY 0 2 2013 <br /> Owner Statements of Designated Underground Storage Tank (U <br /> MIR 3 rel . <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityFacihty #: <br /> Address: 7272 West Lane�Faciffiq Name: uik Stop Market#144 Reason for Submitting this Form(Check One) <br /> - — Stockton,CA 95210 — j ❑ Change of Designated Operator <br /> jacilityPhone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Covan,Jeffrey 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#: 8079216-UC 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 Operator's Phone#: (916)869-0039 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/1/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's <br /> ation to <br /> ST Facility <br /> eck <br /> Business Name(If daffereName: <br /> from above): Walton Engineering,Inc. ❑el U Ch Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 �❑ Service Technician E Third-Party <br /> [International Code Council Certification#: 5261281-UC Expiration Date: 3/1/2015 <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 /> I <br /> SIGNATURE OF TANK OWNER: -fill <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <br /> i <br /> Page 1 <br />