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CUPA: San Joaquin Countyttvironmental Health RECEIVED <br /> • <br /> �,UU192011 <br /> Owner Statements of Designated Underground Storage Tank (UST) Q eepp for <br /> E�VIR�NMENTAL HEALTH <br /> and Understanding of and Compliance with UST Requirements PERMIT/5,ERVICES <br /> Facility Name: Quik Stop Market#152 Facility ID#: #152 <br /> Facility Address: 1721 S.Cherokee Lane#1 Reason for Submitting this Form(Check One) <br /> Lodi,CA 95240 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: Powell,Ryan 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)869-0039 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/14/2013 <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Jeff Covan 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#: 8079216-UC Expiration Date: 9/1/2012 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko 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)826-3200 ❑ 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): Q u,k S4,a /4RR!,et4 4 ,In,c.. 405N'�T 1 <br /> SIGNATURE OF TANK OWNER: `/' / M��✓/ 2 O S pq Z <br /> DATE: /7 0 Q/ / OWNER'S PHONE#: S l V t-f'f$—Z 2 S'S <br /> I <br /> Page 1 <br />