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M � <br />CUPA: <br />• • <br />San Joaquin County Environmental Health -T-,j <br />v <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 # 76 <br />Facility ID #: # 076 <br />Facility Address: 1030 S. Olive Avenue <br />Stockton, CA 95215 <br />Reason for Submitting this Form (Check One) <br />■ Change of <br />Facility Phone #: 510-657-8500 <br />❑ Update Cert i a <br />5307857 -UC <br />Designated UST Operators) for this Facility MAY 3 1 2007 <br />ENVIRONMENT HEALTH <br />PRIMARY <br />Designated Operator's Name: Greg Copp Relation to UST Facility (C eck One) <br />Business Name (If different from above): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: (916) 826-3082 10 Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC I Expiration Date: 2/16/2008 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Darren Sciume 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) 825-3203 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5261281 -UC Expiration Date: 3/31/2009 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Michael Krull <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-3203 <br />International Code Council Certification #: <br />5307857 -UC <br />Expiration Date: 3/31/2009 <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 z /4,z ✓ r z,) 4 4, ✓L. a f kap. R 4ift T <br />SIGNATURE OF TANK OWNER: ir r /_ �l 4,t 0 ,;1 G S40 4 �C �s • , ZNc . <br />DATE: - 2,7— 67 OWNER'S PHONE #: L,,e-1,3) C J7 — kS 00 <br />T <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.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />Page 1 <br />