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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of and Compliance with UST Requirpmn 53? AIA <br /> Facility Name: Emils Liquors Facility ID#: FA0000306 <br /> Facility Address: Reason for Submitting this Form (check one) <br /> 1405 California St. [IChange of Designated Operator <br /> Escalon, Calif. 95320-1702 <br /> Update Certificate Expiration Date <br /> Facilit Phone #: <br /> Designated UST Operator(s) for this Facility <br /> Primary <br /> Designated Operator's name: Dan Mcllrath Relation to UST Facility (check one) <br /> Business Name: Valley Underground Tank Monitoring ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: (209)476-1805 ❑ Service Technician UThird-party <br /> International Code Council Certification #:XX4141012575 Expiration Date: 11/13/2096_] <br /> Alternate 1 <br /> Designated Operator's name: Relation to UST Facility(check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification #: Ex iration Date: <br /> Alternate 2 <br /> Designated Operator's name: 1 Relation to UST Facility (check one) <br /> Business Name: ❑Owner ❑Operator ❑Employee <br /> Designated Operator's Phone #: ❑ Service Technician ❑ Third-party <br /> International Code Council Certification lExpiration Date: <br /> Note: THE LOCAL REGULATORY AGENCY MUST BE NOTIFIED OF ANY CHANGES TO <br /> THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> I certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designatd UST Operator(s). The individual(s) will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, <br /> title 23, section 2715 (C) - (F). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, <br /> and local ordinances) applicable to underground storage tanks. <br /> Name of Tank Owner <br /> or Owner's Agent(Please Print): Chacko Thomas <br /> Signature of Tank <br /> Owner or Owner's Agent: _ <br /> Date: 01/03/2005 Owner's Phone#-. (209)838-7674 <br />