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0 4 RECEIVED <br /> CUPA: San Joaquin County Environmental Health <br /> Owner Statements of Designated Underground Storage Tank (UST) r r2013 <br /> and Understanding of and Compliance with UST Require <br /> 11EALFI-1 DEPARTMENT <br /> Flaaccility Name Quik Stop Market#138 Facility ID#: #138 <br /> Facility Address: 1153 Lincoln Blvd. Reason for Submitting this Form(Check One) <br /> Tracy,CA 95376 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Covan,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 /> _--- -- <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 Operator's 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 /> Business Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (916)826-3138 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5261281-UC Expiration Date: 3/1/2015 <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 /> � / I <br /> SIGNATURE OF TANK OWNER: �( <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <br /> Page I <br />