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CUPA: San Joaquin County ,environmental Health <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 # 39 Facility ID #: # 039 <br />Facility Address: 2285 E. Fremont Street Reason for Submitting this Form (Check One) <br />Stockton, CA 95205 ❑ Change of Designated Operator <br />Facilitv Phone #: 510-657-8500 ■ Update Certificate Expiration Date <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Powell, Ryan 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) 869-0039 ❑ Service Technician ■ Third -Party <br />[nternational Code Council Certification #: 5257345 -UC Expiration Date: 3/28/2011 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Jeff Covan 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 />[nternational Code Council Certification #: 8079216 -UC Expiration Date: 9/1/2012 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Mike Holkko <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) 826-3200 <br />International Code Council Certification #: <br />8025470 -UC <br />Expiration Date: 2/2/2012 <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): <br />SIGNATURE OF TANK OWNER: <br />,9.z. Q S <br />DATE: Ak ✓• q 00/0 OWNER'S PHONE #: L15A d) 41115 " Z Z FS S <br />ECEIVEC <br />Nov 15 �j o <br />ENVIRONMEN7-AL H <br />PERMIIT/SERVICEES hl <br />Page 1 <br />