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CUPA: San Joaquin CountyInvironmental Health <br /> RvF <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#148 Facility ID#: #148 <br /> Facility Address: 205 W.Lockeford Street Reason for Submitting this Form(Check One) <br /> Lodi,CA 95240 ■ Change <br /> Facility Phone#: 510-657-8500 ❑ Update i <br /> Designated UST Operator(s) for this Facility MAY 3 1 2007 <br /> PRIMARY <br /> ENVIRONMENT HEALTH <br /> Designated Operator's Name: Greg Copp Relation to US <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3082 ❑ Service Technician ■ Third-Parry <br /> International Code Council Certification#: 5278409-UC Expiration Date: 2/16/2008 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Darren Sciume 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)825-3203 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date: 3/31/2009 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Michael Krull 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)825-3203 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5307857-UC 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. Q y <br /> NAME OF TANK OWNER(Please Print):ZM/.fC� R 1/L L d /" �J�2. a ��/t/• rl 941 P*- <br /> SIGNATURE OF TANK OWNER: -- 2 It ShfZ'y C . <br /> DATE: S'Z 9— d7 OWNER'S PHONE#: �Sl O' 7- ?,5�0 0 <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 agvs.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 />