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CUPA: San Joaquin County Environmental Health <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#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 /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated O rator's Name: Carpenter,Curtis Relation to UST Facility(Check One) <br /> Business Name(If dWerent from above): Walton Engineering,Inc. la Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)825-7857 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8167865-UC Expiration Date: 3/20/2015 <br /> ALTERNATE 1(Optional) <br /> ................_-..._ __ ..............----- <br /> Designated Operator's Name: Bill Culp Relation to UST Facility(Check One) <br /> Business Name(Ff dierent from above): Walton Engineering,Inc. ❑ Owner ❑ Operator 11 Employee <br /> Designated Operator's Phone#: (916)826-3065 11 Service Technician ■ Third-Party <br /> International Code Council Certification#: 8251286 Expiration Date: 3/1812016 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Chris Kuykendall Relation to UST Facility(Check One) <br /> Business Name(If dierent from above): Walton Engineering,Inc. O Owner ❑ Operator El Employee <br /> Designated Operator's Phone#: (916)826-6951 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8161927-UC Expiration Date: 5/13/2016 <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}: V-OG C-R- IBS'72A- <br /> SIGNATURE OF TANK OWNER: (Z,� <br /> DATE: 7-1-14 OWNER'S PHONE M S t 0 6 S'7— $S n C_> <br />