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CUPA: San Joaquin County Wironmental Health Li %t(�'�1'��r (��D MAR -- 7 2008 Owner Statements of Designated Underground Storagf6��, gator PFvil and Understanding of and Compliance with UST equlrements pt/ Facility Name: Quik Stop Market #125 Facility ID #: # 125 Facility Address: 1580 W. Main Street Ripon, CA 95366 Reason for Submitting this Form (Check One) ❑ Change of Designated Operator Facility Phone #: 510-657-8500 ■ Update Certificate Expiration Date Designated UST Oaerator(s) for this Facility PRIMARY Designated Operator's Name: Greg Copp Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): Walton Engineering, Inc. Designated Operator's Phone #: (916) 826-3082 International Code Council Certification #: 5278409 -UC Expiration Date: 1/29/2010 ALTERNATE 1 (Optional) Designated Operator's Name: Darren Sciume Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): Walton Engineering, Inc. Designated Operator's Phone #: (916) 825-3203 International Code Council Certification #: 5261281 -UC Expiration Date: 3/31/2009 ALTERNATE 2 (Optional) Designated Operator's Name: Michael Krull Relation to UST Facility (Check One) ❑ Owner ❑ Operator ❑ Employee ❑ Service Technician ■ Third -Party Business Name (If different from above): Walton Engineering, Inc. Designated Operator's Phone #: (916) 825-3203 International Code Council Certification #: 5307857 -UC Expiration Date: 3/31/2009 I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s) will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER (Please Print): SIGNATURE OF TANK OWNER: DATE: 3 -" `f — d X OW-4j<STO/o /Y%2�«'�S� -7,;lG. C., Qw;!< Sop 14,4__ cc= 1s, Svc. OWNER'S PHONE NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.gov/ust/contacts/cupa aqvs.html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. November 2004 Page 1