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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 Facility ID#: 144 <br /> Facility Address: 7272 West Lane Reason for Submitting this Form(Check One) <br /> Stockton, CA 95210 IN Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Roger W Clark Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfromabove): Walton En ineerin% Inc. ❑ Owner ❑ Operator C3 Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician © Third-Party <br /> International Code Council Certification#: 5256794-UC Expiration Date: July 21, 2007 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Gregory Copp Relation to UST Facility(Check One) <br /> Business Name(If dierentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician M■ Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Date: February 16, 2008 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Lawrence M Lawrence Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfromabove): Walton Engineering, Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: 916-825-3203 ❑ Service Technician M Third-Party <br /> International Code Council Certification#: 1048103-UC 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): /y k� AR✓id o f *JA Qu;k Sj6p Wk f r- -Tvc.. <br /> SIGNATURE OF TANK OWNER: a i <br /> DATE: C/—Z`r O(0 OWNER'S PHONE#: fid, �o S�7- 504 <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 agvs.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />