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APR 2 0 1010 <br />CUPA: San Joaquin Countytnvironmental HealthTH <br />ENUjgp�I+AE{VT H>=AL <br />PRIERVICES <br />Owner Statements of Designated Underground Storage Tank T) Operator <br />and Understanding of and Compliance with UST Requirements <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 />i <br />Lodi, CA 95240 ❑ Change of Designated Operator <br />Facility Phone #: 510-657-8500 ■ Update Certificate Expiration Date -i <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Copp Gregory IRelation 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 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC Expiration 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 ❑ Service Technician ■ Third -Party <br />- <br />International Code Council Certification #: 5307848 -UC ----Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification # <br />Mike Holkko <br />Walton Engineering, Inc. <br />(916)826-3200 <br />8025470 -UC - <br />- - Relation to UST Facility (Check One) <br />- - -� ❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />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): Iy"kce, Anyc L0, 4A m4nkL4,r I 7o, . <br />SIGNATURE OF TANK OWNER: <br />DATE: N — / S- 21010 OWNER'S PHONE #: (51t0) q,15 - <br />Page <br />y5 - <br />Page 1 <br />