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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <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#: 5107657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Operators) for this Facility <br /> ALTERNATE 3(Optional) <br /> Designated Operator's Name: Carpenter,Curtis 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)825-7857 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8167865-UC Expiration Date: 3/20/2015 <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Chris Kuykendall Relation to UST Facility(Check One) <br /> ------------------ <br /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-6951 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8161927-UC Expiration Date: 6/8/2014 <br /> ALTERNATE 5 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date. <br /> i <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): Michael Karvelot <br /> SIGNATURE OF TANK OWNER: �( <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <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: .wateroards.ca. ov/ust/contacts/cua aays.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Page 2 <br />