Laserfiche WebLink
CUPA: <br />San Joaquin CountyOnvironmental Health <br />r_ <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quik Stop Market # 39 <br />Facility ID #: # 039 <br />Facility Address: 2289 E. Fremont Street <br />Stockton, CA 95205 <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 Operators) 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 />tLTERNATE 1 (Optional) <br />3esignated Operator's Name: Alex Fast Relation to UST Facility (Check One) <br />3usiness Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />3esignated Operator's Phone #: (916) 869-0023 ❑ Service Technician ■ Third -Party <br />nternational Code Council Certification #: 5307848 -UC Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: 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 #: 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 />/ <br />NAME OF TANK OWNER (Please Print): XKAy /'b A VA:: [,d / 2 6,.;I< S40 ��ltr• , 1.1 G . <br />SIGNATURE OF TANK OWNER: ��M✓^��✓I <br />DATE: y — / 7 — 4 �/ OWNER'S PHONE #: <5'/6 — <br />Page 1 <br />