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9 <br />CUPA: San Joaquin County Environmental Health <br />Do <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with UST Requirements <br />Facility Name.Quik <br />Stop Market #148 <br />Facility ID #: # 148 <br />.. ............... <br />Facility Address: <br />205 W. Lockeford Street <br />Lodi, CA 95240 <br />Reason for Submitting this Form (Check One) <br />o Change of Designated Operator <br />Facility Phone M <br />510-657-8500 <br />0 Update Certificate Expiration Date <br />Designated UST Operatoros for this Facility <br />PRIMARY <br />Designated Operator's Name: <br />Carpenter, Curtis <br />Relation to UST Facility (Check One) <br />0 Owner E) Operator 0 Employee <br />0 Service Technician 0 Third -Party <br />Business Name (If different from above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 825-7857 <br />International Code Council Certification <br />8167865 -UC <br />Expiration Date: 3/2012015 <br />ALTERNATE I (Ontional) <br />Designated Operator's Name: <br />Bill Culp <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 Service Technician M Third -Party <br />Business Name (If different froin above): Walton Engineering, Inc. <br />Designated Operator's Phone W: (916) 826-3065 <br />International Code Council Certification #: <br />8251286 <br />Expiration Date: 3/18/2016 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Chris Kuykendall <br />Relation to UST Facility (Check One) <br />0 Owner 0 Operator 0 Employee <br />0 Service Technician 0 Third -Party <br />Business Name (If dikerentfrom above): Walton Engineering, Inc. <br />Designated Operator's Phone #: (916) 826-6951 <br />International Code Council Certification <br />8161927 -UC <br />Expiration Date: 5/13/2016 <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): R.06c—rL- 'B?11MA— <br />SIGNATURE OF TANK OWNER: <br />DATE: 7-1-14 OWNER'S PHONE #: S 10 — G S -j — R S 0 0 <br />t'N I <br />0AA0 W <br />