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CUPA: San Joaquin CountyOnvironmental Health <br />APR 15 2009 <br />Owner Statements of Designated Underground Storage Tank (UST Operator <br />SAN JOAQUIN COUNTY <br />and Understanding of and Compliance with UST Requirementswi;f ,O,'v[--,3,TAL <br />HEALTH Dcc",•:,MMENT <br />Facility Name: Quik Stop Market #144 <br />Facility ID #: #1" <br />Facility Address: 7272 West Lane <br />Stockton, CA 95210 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />Facility Phone #: 510-657-8500 <br />■ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Greg Copp <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-3082 <br />International Code Council Certification #: <br />5278409 -UC <br />Expiration Date: 1/29/2010 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Alex Fast <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 869-0023 <br />International Code Council Certification #: <br />5307848 -UC <br />Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Ryan Powell <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-3084 <br />International Code Council Certification #: <br />5257345 -UC <br />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): Afll<4= /S194✓e'Lc) . tae 01-.;% S144 lgA44._ J1)C . <br />SIGNATURE OF TANK OWNER: <br />DATE: Y-13-67 OWNER'S PHONE #: .5'16 — J4 q.5' — Z Z 8'S <br />Page 1 <br />