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41 RECEIVED <br /> ft 4 <br /> CUPA: San Joaquin County nvironmental Health <br /> MAYO 2 2013 <br /> Owner Statements of Designated Underground Storage Tank (UST) O erator <br /> and Understanding of and Compliance with UST RequiremAL <br /> IR l� l�A ENT <br /> MENT <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 j <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Govan,Jeffrey 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 /> International Code Council Certification#: 8079216-UC Expiration Date: 8/27/2014 <br /> ALTERNATE 1 (Optional) <br /> Designated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone# (916)869-0039 ❑ Service Technician 0 Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/1/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Darren Sciume Relation to UST Facility(Check One) <br /> i Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 ❑ Service Technician N Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date. 3/1/2015 <br /> i <br /> 1, 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 /> i <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): Michael Karveloott <br /> SIGNATURE OF TANK OWNER: - �[ <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <br /> i <br /> Page I <br />