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1REGENEU <br /> CUPA: San Joaquin County Environmental Health APR 2 0 <br /> 2010 <br /> SOWNT HEALTH <br /> Owner Statements of Designated Underground Storage TaE nM"flw% <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 Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Copp,Gregory - Relation to UST Facility(Check One) <br /> ,Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: (916)826-3082 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5278409-UC [Expiration Date: 1/26/2012 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Alex Fast 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#. 530 848 UC Expiration Date 3/14/2011 - <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above): Walton Engineering,Inc. J!,❑ 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): / ,'1<A;,e %1IR✓k:Z0 t 4m Mgnkw4s, . <br /> SIGNATURE OF TANK OWNER: <br /> DATE: q- 15- 2010 OWNER'S PHONE#: �S10) A/'f S- Z Z g S <br /> Page 1 <br />