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CUPA: San Joaquin County Sironmental Health <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <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 ❑ Update Certp�:Fygpta <br />Designated UST Onerator(s) for this Facility <br />PRIMARY <br />MAY 3 1 2007 <br />ALTF,RNATF. 1 /Ontionah <br />Designated Operator's Name: <br />Darren Sciume <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-3203 <br />International Code Council Certification #: <br />5261281 -UC <br />Expiration Date: 3/31/2009 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: Michael Krull <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ■ Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-3203 <br />International Code Council Certification #: 5307857 -UC <br />Expiration Date: 3/31/2009 <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): / I'111-0- KARVO'L d �t 2 , o 15V V. RS <br />SIGNATURE OF TANK OWNER: I�' (. � `__� V,) 2 Sid t "I �� fs • C <br />DATE: -5— 2 %— 0 % OWNER'S PHONE #: � 0) �% $ J�6 O <br />T• <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: www.waterboards.ca.gov/ust/contacts/cupa agys.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />Page I <br />