Laserfiche WebLink
CUPA: San Joaquin County(pnvironmental Health <br />iRECE-,!",r <br />APR 15 2000 <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 10121 <br />Facility ID #: # 121 <br />Facility Address: 1196 W. Louise Avenue <br />Manteca, CA 95336 <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 Operator(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: <br />Alex Fast <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 />5307848 -UC <br />Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />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 #: <br />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 />� <br />NAME OF TANK OWNER (Please Print): �`� nvvlO / 4tz w" k S4 4 Alldr .INC . <br />SIGNATURE OF TANK OWNER: <br />DATE: Al -13 U q OWNER'S PHONE #: sl d- <br />Page 1 <br />