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r <br /> CUPA: San Joaquin County Environmental Health SEP 1 0 2012 <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#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 Operators, for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Covan,Jeffrey 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: 8/27/2014 — <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Ran Powell Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator 11 Employee <br /> Designated Operator's Phone# (916)869-0039 ❑ Service Technician ■ Third-Party <br /> -- ---- <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/14/201 _j <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Darren Sciume lRelation to UST Facility(Check One <br /> Business Name(If different from above): Walton Engineering,Inc. Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC xpiration Date: 3/14/2013 <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): Michael Karvelot <br /> SIGNATURE OF TANK OWNER: -of <br /> DATE: 9-1-27 OWNER'S PHONE#: 510-657-8500 <br /> i <br /> Page 1 <br />