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tA% qp RECEIVED <br /> CUPA: San Joaquin County,environmental Health -0 <br /> MAY 0 2 2013 <br /> Owner Statements of Designated Underground Storage Tank (US <br /> MMENTAL <br /> and Understanding of and Compliance with UST Requiremer> LTli l E'RARTM -r <br /> [Facc i jlty Name: Quik Stop Market#121 Facility ID#: # 121 <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 0 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Cowan,Jeffrey Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator El Employee <br /> Designated Operator's Phone#: (916)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8079216-UC Expiration Date: 8/27/2014 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Ryan Powell 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 E Third-Party <br /> ' <br /> International Code Council Certification#: 5257345-UC ,,Expiration Date: 3/1/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Darren Sciue Relation to UST Facility(Check One) <br /> m <br /> --- — - - -- <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC -i Expiration Date: 3/1/2015 <br /> i <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 /> I <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): Michael Karveloott <br /> SIGNATURE OF TANK OWNER: I �C <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <br /> i <br /> Page 1 <br />