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E <br />CUPA: San Joaquin County Environmental Health <br />L] <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 <br />Facility ID M # 148 <br />Facility Address: 205 W. Lockeford Street <br />Lodi, CA 95240 <br />Reason for Submitting this Form (Check One) <br />■ U date Certificate Expiration Date <br />Facility Phone #: 510-657-8500 <br />❑ Change of Designated Operator <br />Desienated UST Ouerator(s) for this Facility <br />PVTMARV <br />Designated Operator's Name: <br />Carpenter, Curtis <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name 1 di erent om above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 373-1166 <br />International Code Council Certification #: <br />8167865 -UC <br />Expiration Date: 2/5/2019 <br />ALTERNATE I (Optional) <br />DesignatedOperator's Name: Harold Largo Relation to UST Facility (Check One) <br />Business Name I di Brent om above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />DesignatedOperator's Phone #: (916) 373-1166 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 8293993 Expiration Date: 11/13/2018 <br />ALTERNATE 2 (Optional) <br />DesignatedOperator's Name: Relation to UST Facility (Check One) <br />Business Name (I di erenP oin above): ❑ Owner ❑ Operator ❑ Employee <br />Desi nated Operator's Phone M ❑ Service Technician M Third -Party <br />International Code Council Certification #: Expiration Date: <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): X044- i-.. &Arp-A— <br />SIGNATURE OF TANK OWNER: Lift= IQyiu- <br />Date: 12/29/2016 Owner's Phone #: S/ a ' 6 '7 " $ �� <br />