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CUPA: San Joaquin County hnvironmental Health <br /> Owner Statements of Designated Underground Storage Tank (UST) Ope and Understanding of and Compliance with UST Requirement 1 <br /> �qN jO� <br /> F C?Ulrb <br /> Facility Name: Quik Stop Market#148 Facility ID#: #14 FACT MFNT <br /> Facility Address: 205 W.Lockeford Street Reason for Submitting this Form(C e rr <br /> Lodi,CA 95240 ❑ Change of Designated Operator <br /> Facility Phone#: 510-657-8500 ■ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Powell,Ryan 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)869-0039 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/14/2013 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Jeff Covan 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)869-0023 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 8079216-UC Expiration Date: 9/1/2012 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Mike Holkko 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)826-3200 ❑ 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 A Aunderground storage tanks. <br /> NAME OF TANK OWNER(Please Print): 0",a< s4ro 41t-64: I TN C.. /QSN 1> <br /> SIGNATURE OF TANK OWNER: <br /> DATE: �u q. !7, 2 U l I OWNER'S PHONE#: x{11$—ZZS,S <br /> Page 1 <br />