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a <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 <br />Facility ID #: 144 <br />Facility Address: 7272 west Lane <br />Stockton, CA 95210 <br />Reason for Submitting this Form (Check One) <br />E Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone #: 510-657-8500 <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Bruce N Stewart <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 #: 916-825-3203 <br />International Code Council Certification #: <br />5249892 -UC <br />Expiration Date: July 28, 2007 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Richard S Walton <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician S Third -Party <br />Business Name (If diiferentfromabove): Walton Engineering, Inc. <br />Designated Operator's Phone #: 916-825-3203 <br />International Code Council Certification #: <br />55243762 -UC <br />Expiration Date: October 12, 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/fit: AAR ✓CZ0/� - " <br />SIGNATURE OF TANK OWNER: <br />DATE: OWNER'S PHONE #: /) (S7- g'SO 0 <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.ov/ustJcontacts/cupa ays.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />