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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quik Stop Market <br />Facility ID #: 76 <br />Facility Address: 1030 S. Olive Avenue <br />Stockton, CA 95215 <br />Reason for Submitting this Form (Check One) <br />M Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 510-657-8500 <br />Designated UST Overator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Roger W Clark <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑■ Third -Party <br />Business Name (If differentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-82'55-3203 <br />International Code Council Certification #: <br />552556794 -UC <br />Expiration Date: July 21, 2007 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Gregory Copp <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician M■ Third -Party <br />Business Name (If differentfrom above): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-8255-3203 <br />International Code Council Certification #: 5278409 -UC <br />Expiration Date: February 16, 2008 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Lawrence M Lawrence <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician N Third -Party <br />Business Name (If differentfrom above): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-825-3203 <br />International Code Council Certification #: <br />1048103 -UC <br />Expiration Date: October 14, 2006 <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): /411 %�' �\ / MVC- to R Qwi k Vd,2 /4kix-, Zyr_. <br />SIGNATURE OF TANK OWNER: <br />DATE: — Z F!(— OWNER'S PHONE #: LSi0 G S % - 8 SOU <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.pov/ust/contacts/cupa aevs.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />