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' CEV E LJ <br />q <br />CUPA: San Joaquin CouCounty Environmental Health APR 2 0 2010 <br />I ENT HEALTH <br />M <br />Owner Statements of Designated Underground Storage T���c Mr <br />and Understanding of and Compliance with UST Requirements <br />Facility Name: Quik Stop Market #121 Facility ID #: # 121 <br />(Facility Address: 1196 W. Louise Avenue Reason for Submitting this Form (Check One) <br />Manteca, CA 95336 ❑ Change of Designated Operator <br />,Facility Phone #: 510-657-8500 1 • Update Certificate Expiration Date <br />Desianated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Copp, Gregory - <br />_I Relation to UST Facility (Check One) <br />Business Name (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />I Designated Operator's Phone #: <br />(916) 826-3082 <br />❑ Service Technician ■ Third -Party <br />International Code Council Certification #: <br />5278409 -UC <br />Expiration Date: 1/26/2012 <br />ALTERNATE 1 (Optional) <br />Designated Operators Name: <br />Alex Fast <br />1 Relation to UST Facility (Check-One)- <br />heckOne)Business <br />BusinessName (If different from above): <br />Walton Engineering, Inc. <br />❑ Owner ❑ Operator ❑ Employee <br />Designated Operators 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 (Ifdifferent 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): Mr At- I�,qRVcz o ik .SI»» 02 /lARI«ds-, XNG . <br />SIGNATURE OF TANK OWNER: ` I-* (. �l <br />DATE: 41 — / S — ZO l O OWNER'S PHONE #: �StOJ �'t 5-22-8"5 <br />Page 1 <br />00 <br />