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El <br /> i , <br /> aim <br /> CUPA: San Joaquin Coun kironmental Health <br /> q tY I . <br /> Owner Statements of Designated Underground Storage Tank (UST)*&RtQr11 <br /> and Understanding of and Compliance with UST Requirernialts ,, . ,,,,COUNTY <br /> Ed�VI v i v; .N;T <br /> AI <br /> Facility Name: Quik Stop Market#121 Facility ID#: 124H DEPAH-rMENT <br /> Facility Address: 1196 W.Louise Avenue Reason for Submitting this Form(Check One) <br /> Manteca,CA 95336 ❑ 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 Operator's Name: Powell,Ryan 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)869-0039 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/14/2013 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Jeff Covan 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#: 8079216-UC Expiration Date: 9/1/2012 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko 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)826-3200 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8025470-UC 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): Oj u-t k %/o <br /> SIGNATURE OF TANK OWNER: �l �r>•t Q sm,I <br /> DATE: ��y, /7 , ZV/ / OWNER'S PHONE#: <br /> Page 1 <br />