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RF <br />CUPA: San Joaquin County Environmental Health <br />APR 2 0 2010 <br />Owner Statements of Designated Underground Storage Tank ('HEALTH <br />and Understanding of and Compliance with UST RequiVFMI(MIfISERVICES <br />Facility Name: Quik Stop Market #120 =Facility ID #: # 120 <br />Facility Address: 9321 Thornton Road Reason for Submitting this Form (Check One) <br />Stockton, CA 95209 ❑ Change of Designated Operator <br />Facility Phone #: 510-657-8500 ■ Update Certificate Expiration Date -I <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: - <br />Copp, Gregory - <br />Relation to UST Facility (Check One) <br />Business Name (Ifdifferent from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator'serator's Phone <br />(916) 826-3082 <br />❑ Service Technician ■ Third -Party <br />Code Council Certification #: <br />- <br />5278409 -UC <br />Expiration Date. 1/26/2012 <br />ALTERNATE 1 (Optional) <br />Designated Operator's Name: <br />Alex Fast <br />Relation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operator's Phone #: <br />(916) 869-0023 <br />❑ Service Technician ■ Third -Party <br />[International Code Council Certification #: <br />5307848 -UC <br />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. El Owner ❑ Operator El 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): Nk = k,9AV4z16 -t ri 04k S4P /V%A2kt-4s .INC , <br />SIGNATURE OF TANK OWNER: <br />DATE: H —1!5'- 2.610 OWNER'S PHONE #: �5t Ol K -15- - 2-2 S'S <br />Page 1 <br />