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jok (.9 <br />C1JPA: San Joaquin County tvironmental 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 #125 Facility ID #: # 125 <br />Facility Address: 1580 W. Main Street Reason for Submitting this Form (Check One) <br />Ripon, CA 95366 ■ Change of Designated Operator <br />Facility Phone #: 510-657-8500 ❑ Update Cert4&fff9s 4&0W4¢ - �° <br />Desienated UST ODerator(s) for this Facili <br />MAY 3 1 2007 <br />PRIMARY <br />Designated Operator's Name: Greg Copp Relation to US �e <br />Business Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator �❑ 1110i <br />Designated Operator's Phone #: (916) 826-3082 ❑ Service Technician ■ Third -Party <br />International Code Council Certification.#: 5278409 -UC Expiration Date: 2/16/2008 <br />tLTERNATE 1 (Optional) <br />3esignated Operator's Name: Darren Sciume Relation to UST Facility (Check One) <br />3usiness Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />3esignated Operator's Phone #: (916) 825-3203 ❑ Service Technician ■ Third -Party <br />ntemational Code Council Certification #: 5261281 -UC Expiration Date: 3/31/2009 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Michael Krull <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) 825-3203 <br />International Code Council Certification #: <br />5307857 -UC <br />Expiration Date: 3/31/2009 <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): �%K t� /(AA ✓C -:L 0 ���.. 0i' Alt/ 4Fg1fZ, r <br />SIGNATURE OF TANK OWNER: `%�' / . ��yy-/ . d -d ✓t �w �<- SYd /� /Y(�Z r s • , Z -'v C . <br />DATE: -5— 2 9 - 0 7 <br />OWNER'S PHONE #: 6 / 0 6,5-7- S.S-O 0 <br />Ti <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE STATE WATER <br />RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />Page 1 <br />