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1 <br />J. nr IsRECzym 1�v <br />CUPA: San Joaquin County Environmental Health APR 2 0 2010 <br />Owner Statements of Designated Underground Storage Tank (y ~f4#EAjH <br />and Understanding of and Compliance with UST RequireRMT/sERVICES <br />!Facility Name_ - Quik Stop Market #138 ,Facility ID #: # 138 <br />Facility Address: 1153 Lincoln Blvd. Reason for Submitting this Form (Check One) <br />Tracy, CA 95376 - ❑ Change of Designated Operator <br />rd--ty Phone #: 510-657-8500 1 ■ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Copp, Gregory -- 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) 826-3082 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC Expiration Date: 1/26/2012 J <br />ALTERNATE i (Optional) <br />Designated Operator's Name: Alex Fast ?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 #: 5307848 -UC Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Business Name (If different from above)-:-- <br />Designated <br />bove)-Designated Operator's Phone #: <br />International Code Council Certification # <br />Mike Holkko <br />Walton Engineering, Inc. <br />to 161 <br />OVL''f /v -U\. <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third-Party <br />1Expiration 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. J <br />NAME OF TANK OWNER (Please Print): iItA' 1i' AVJ,4 Lo l_ -A2 Qw-k SY!p M,QZk� Ts Xv C . <br />SIGNATURE OF TANK OWNER: <br />DATE: — /S- ZO/ O OWNER'S PHONE #: <br />Page 1 <br />