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CUPA: San Joaquin Count0vironmental Health <br />ip SEC"D <br />Owner Statements of Designated Underground Storage Tank (UST) C7perafor009 <br />and Understanding of and Compliance with UST Requirem so" f UN -Pe <br />Facility Name: Quik Stop Market #138 <br />Facility ID #: # 138 <br />Facility Address: 1153 Lincoln Blvd. <br />Tracy, CA 95376 <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 Ouerator(s) 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 />ALTERNATE 1 (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 10 Service Technician ■ Third -Party <br />International Code Council Certification #: 5307848 -UC I 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 />NAME OF TANK OWNER (Please Print): �%&r, l ' VL:r- rt dam•• �C S�t4 Al/'I(r <br />SIGNATURE OF TANK OWNER: <br />DATE:g — / 3 — Q q OWNER'S PHONE #: SrlO — 'V 4L S- Z <br />Page 1 <br />