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CUPA: <br />San Joaquin County Environmental HealthAPR 2 0 Z010 <br />� G3EC[ECW[EDAG <br />Owner Statements of Designated Underground Storage Tank (UST)NT HEALTH <br />ISMERVICES <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: <br />Facility Address: <br />'Facility Phone #: <br />Quik Stop Market #148 <br />205 W. Lockeford Street <br />Lodi, CA 95240 <br />510-657-8500 <br />Facility ID #: # 148 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />■ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Copp, Gregory j 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) 826-3082 1 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC - LExpiration 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 1 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5307848 -UC Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Mike Holkko JRelation to UST Facility (Check One) <br />F — - <br />Business Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 826-3200 i ❑ 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 Co <br />Regulations, title 23, section 2715(c) - (f). to <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): M -11-11e kfilk j_ Loa`_ tyle Quik Sato MAAkg4 s .raG . <br />SIGNATURE OF TANK OWNER: <br />DATE: OWNER'S PHONE #: (tea) Ajd 5— ZZFl$ <br />Page 1 <br />