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HECEIVED <br /> CU San Joaquin County�nvironmental Health • <br /> AUG 19 2011 <br /> Owner Statements of Designated Underground Storage Tank (UST) 0WAA&IN COUNTr <br /> and Understanding of and Compliance with UST Requlrement� �F-A �H pEP�rTAL <br /> MENT <br /> Facility Name: Quik Stop Market#120 Facility ID#: #120 <br /> Facility Address: 9321 Thornton Road Reason for Submitting this Form(Check One) <br /> Stockton,CA 95209 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Onerator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Powell,Ryan 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: 3/14/2013 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Jeff Covan 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#: 8079216-UC Expiration Date: 9/1/2012 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko 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)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): �j u� 1< S'� A4,thZ4<7-4 T�1 C <br /> SIGNATURE OF TANK OWNER: —141[. ✓L Q S I <br /> DATE: At&!r. / 7, Z ! / OWNER'S PHONE#: (-S/d) `HS-Z28'S <br /> T- <br /> Page 1 <br />