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CUPA: San Joaquin Countyhvironmental Health <br />Owner Statements of Designated Underground Storage Tank (UST) 0�4at <br />and Understanding of and Compliance with UST Requirem.6 "r <br />Facility Name: Quik Stop Market #138 <br />'Facility ID #: # 138 OFp N�� <br />Facility Address: 1153 Lincoln Blvd. <br />Tracy, CA 95376 <br />Reason for Submitting this Form ( pne) <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 />Powell, Ryan <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) 869-0039 <br />International Code Council Certification #: <br />5257345 -UC <br />Expiration Date: 3/14/2013 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Jeff Covan <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 />8079216 -UC <br />Expiration Date: 9/1/2012 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Mike Holkko <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) 826-3200 <br />International Code Council Certification #: <br />8025470 -UC <br />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): Qwc k J4-,4� m4rt kk-4 � 1,1o_ <br />SIGNATURE OF TANK OWNER: ' e�j R, QS M L <br />DATE: !-tt�q , /7. 201 1 OWNER'S PHONE #: lSlCZZ8$ <br />Page 1 <br />