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RECEIVED <br /> CUPA: San Joaquin County Environmental Health <br /> MAY 0 2 2x,13 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirem%IRONMENTAL <br /> LTH DEPAR-jMENT <br /> Facility Name: Quik Stop Market N 39 Facility ID#: #039 —7, <br /> Facility Address: 2285 E.Fremont Street Reason for Submitting this Form(Check One) <br /> Stockton,CA 95205 I_p_Change ofDesignated Operator <br /> Facility Phone#: 510-657-8500 0 Update Certificate Expiration Date <br /> Designated UST Operator(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. 0 Owner 0 Operator 0 Employee <br /> 'Designated Operator's Phone#- (916)869-0023 1 0 Service Technician 0 Third-Party <br /> LFInternktional 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. 11 Owner 0 Operator El Employee <br /> Designated Operator's Phone# (916)869-0039 1-1 Service Technician Ill Third-Party <br /> I- : <br /> International Code Council Certification#: 5257345-UC Expiration Date3/1/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Darren Sciume Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentfrom above): Walton Engineering,Inc. D Owner 0 Operator El Employee <br /> Designated Operator's Phone#: (916)826-3138 El Service Technician 0 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 /> SIGNATURE OF TANK OWNER: -of <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <br /> Page 1 <br />