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1 0 RECENED <br /> CUPA: San Joaquin Countycironmental Health MAY 0 2 2013 <br /> Owner Statements of Designated Underground Storage Tank (UST�PT"MENTAL <br /> and Understanding of and Compliance with UST Requirement§ALTi� DEPARTMENT <br /> Facility Name: Quik Stop Market#148 Facility ID#: #148 <br /> Facility Address: 205 W.Lockeford Streeteason for Submitting this Form(Check One) <br /> Lodi,CA 95240 o Change of Designated Operator <br /> Facility Phone 510-657-8500 0 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. 11 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#. (916)869-0023 11 Service Technician 0 Third-Party <br /> e <br /> In�tettional Code Council-Certification#: ------ 8079216-UC Expiration Date: ...8/27/2014 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Ryan Powell Relation to UST Facility(Check One) <br /> D <br /> Business Name(If different from above): Walton Engineering,Inc. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: (916)869-0039 0 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 Sciurne Relation to UST Facility(Check One) <br /> Business Name(Ifdifferentftom above): Walton Engineering,Inc. 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: (916)826-3138 0 Service Technician 0 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 /> SIGNATURE OF TANK OWNER: <br /> DATE: 4-20-13 OWNER'S PHONE ft: 510-657-8500 <br /> Page 1 <br />