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r RE(DEUVEUD <br />CUPA: San Joaquin County Environmental Health APR 2 0 2010 <br />q tY <br />�1T HEALTH <br />Owner Statements of Designated Underground Storage Tan ROM <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 />Facility Phone #: 510-657-8500 ■ Update Certificate Expiration Date <br />DesiLmated UST ODerator(s) for this Facili <br />PRIMARY <br />Designated Operators Name: Copp, Gregory 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) 826-3082 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 5278409 -UC Expiration Date: 1/26/2012 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: Alex Fast _ Relation to UST Facility (Check One) <br />Designated Operator's Phone #: ) (916) 869- 023 - El Owner ❑ Operator ❑ Employee <br />Business Name I di Brent rom above): Walton Engineering, Inc. I ❑ Service Technician ■ Third-Part <br />International Code Council Certification #: 5307848 -UC Expiration Date: 3/14/2011 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Mike Holkko 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) 826-3200 ❑ Service Technician ■ Third -Party <br />International Code Council Certification #: 8025470 -UC 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): 11-110149R✓L:11d / ycrlt w -k S44 N%2kx t s <br />SIGNATURE OF TANK OWNER: <br />DATE: Al -15-2,4010 OWNER'S PHONE #: <br />Page 1 <br />