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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Quik Stop Market#148 Facility ID#: #148 <br /> Facility Address: 205 W. Lockeford Street Reason for Submitting this Form(Check One) <br /> Lodi,CA 95240 ❑ Change of Designated Operator <br /> LFacility Phone#.- 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> ALTERNATE 3(Optional) <br /> t <br /> signated Operators Name: Carpenter,Curtis Relation to UST Facility(Check One) <br /> siness Name(If different from above): Walton Engineering,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#: (916)825-7857 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8167865-UC Expiration Date: 3/20/2015 <br /> ALTERNATE 4(Optional) <br /> Designated Operator's Name: Chris Kuykendall 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)826-6951 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8161927-UC Expiration Date: 6/8/2014 <br /> ALTERNATE 5 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑ Service Technician ❑ Third-Party <br /> International Code Council Certification#: Expiration Date <br /> i <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 Karveloott <br /> SIGNATURE OF TANK OWNER: �`M <br /> i <br /> DATE: 4-20-13 OWNER'S PHONE#: 510-657-8500 <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: .waterboards.ca.gov/ust/contacts/cur)a agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> i <br /> i <br /> Page 2 <br />