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RECEIVED <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements MAr 0 9 20112 <br /> Designated UST Operator(s) for this Facility <br /> ENVIRONMENTAL HEALTH <br /> PFR F:Fmf- <br /> Facility Name: Express Market Facility ID#: <br /> Facility Address: 419 S. Main St Reason for Submitting this Form(Check One) <br /> Manteca CA 95337 x Change of Designated Operator <br /> Facility Phone 209 401-5292 1 ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name O'd fferent from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-972-5087 X Service Technician X Third-Party <br /> International Code Council Certification#:8036233-UC Expiration Date: 1-26-13 <br /> ALTERNATE 1 O ho <br /> Designated Operator's Name:Tyne Hardeman Relation to UST Facility(Check One) <br /> Business Name(If different from above).-Franzen-Hill ❑ owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 559-688-2977 X Service Technician X Third-Party <br /> International Code Council Certification#8131628-UC Expiration Date: 11-11-13 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-688-2977 X Service Technician X Third-Party <br /> International Code Council Certification#:5311578-UC Expiration Date: 1-26-13 <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): 717 I 1 Y( <br /> SIGNATURE OF TANK OWNER: <br /> DATE: Z _ OWNER'S PHONE#: Ll <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: aiRVS.i-,i,_, . <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> 1�in..PmhPr �!1(LI <br />