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A C - <br />CUPA: San Joaquin County(nvironmental Health <br />n <br />Owner Statements of Designated Underground Storage TankT)C perator <br />and Understanding of and Compliance with UST Ri'� i g . A J " <br />Facility Name: Quik Stop Market #152 <br />Facility ID #: # 152 <br />Facility Address: 1721 S. Cherokee Lane #1 <br />Lodi, CA 95240 <br />Reason for Submitting this Form (Check One) <br />❑ Change of Designated Operator <br />Facility Phone #: 510-657-8500 <br />■ Update Certificate Expiration Date <br />Designated UST Overator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Greg Copp <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) 826-3082 <br />International Code Council Certification #: <br />5278409 -UC <br />Expiration Date: 1/29/2010 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Darren Sciume <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 />5261281 -UC <br />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 Qf 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): Q w�lc S'�� IV14"'4S) ✓G <br />SIGNATURE OF TANK OWNER: —/-v l . ��``.-� '! d� a ( w • S4Wc- <br />DATE: 3 — Al — O S.*' OWNER'S PHONE #: al a) <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 />