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cuPA: San Joaquin Countpnvironmental Health <br /> Owner Statements of Designated Underground Storage Tank (UST) Q dt(SQ009 <br /> and Understanding of and Compliance with UST Requiremeq ��.•a ,. ©uN n <br /> Facility Name: Quik Stop Market#152 Facility ID#: --­Nt1ENT <br /> Facility Address: 1721 S.Cherokee Lane#1 Reason for Submitting this Form(Check One) <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: Greg Copp 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)826-3082 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5278409-UC Expiration Date: 1/29/2010 <br /> ALTERNATE 1(Optional) <br /> Designated Operator's Name: Alex Fast 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#: 5307848-UC Expiration Date: 3/14/2011 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Ryan Powell 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)826-3084 ❑ Service Technician ■ Third-Party <br /> International Code Council Certification#: 5257345-UC Expiration Date: 3/28/2011 <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): 2<,L "L t/= r d 2 w (< s�o /`PkAr. !A/C. <br /> SIGNATURE OF TANK OWNER: <br /> DATE: —l 3 Q 9 OWNER'S PHONE#: Sed - qq <br /> Page 1 <br />