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CUPA: San Joaquin County#nvironmental Health Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of and Compliance with UST Requirements Facility Name: Quik Stop Market#152 Facility ID#: #152 Facility Address: 1721 S.Cherokee Lane#1 Reason for Submitting this Form(Check One) Lodi,CA 95240 ❑ Change of Designated Operator Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date Designated UST Operator(s) for this Facility PRIMARY Designated Operator's Name: Powell,Ryan Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (916)869-0039 ❑ Service Technician ■ Third-Party International Code Council Certification#: 5257345-UC Expiration Date: 3/28/2011 ALTERNATE 1(Optional) Designated Operator's Name: Jeff Covan Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (916)869-0023 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8079216-UC Expiration Date: 9/1/2012 ALTERNATE 2 (Optional) Designated Operator's Name: Mike Holkko Relation to UST Facility(Check One) Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (916)826-3200 ❑ Service Technician ■ Third-Party International Code Council Certification#: 8025470-UC Expiration Date: 2/2/2012 I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations, title 23, section 2715(c) - (f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. ccam�'",� NAME OF TANK OWNER(Please Print): Q w�dG S7 610 /V/A,2 k l-:�r , o c, , / OJ P I .r� SIGNATURE OF TANK OWNER: 'C' Q SM L DATE: A16 V. 9, Z 0/ OWNER'S PHONE#: NOV 1 5 2010 Page 1 ,;e.•;