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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Facility Name: k 1(Z Facility ID#: <br /> Facility Address(A kC 5. ` Reason for Submitting this Form(Check One) <br /> X Change of Designated Operator <br /> Facility Phone 15S9) ZSR - Z ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Chris Deyoung Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 X Service Technician X Third-Party <br /> Intemational Code Council Certification#: Expiration Date: <br /> ALTERNATE I(Optional) <br /> Designated Operator's Name: Tyne Hardeman Relation to UST Facility(Check One) <br /> 13usinessName(Ifdiifferent from above):Tr 41zen-11111 ic._ � DtiiSter u t`iperaior F.nipio`-- <br /> 1 <br /> Designated Operator's Phone#:(559)688-2977 x Service 1 cc nician =T lard-Pseis <br /> hucmationai Cade Council Certification#: S I i162'i-: i„ Expiration Date: 1111111; <br /> ALI'LM:ATE 2 (Optional) _ <br /> Desi¢nated Orterwnc's Name- _� Relation to UST Facility(Check ate) <br /> Business Name(If dif'erent from above):Franzen-Hill Inc. O Owner ❑ Operator ❑ Employee <br /> [ ^csignatcd Operator's Phot;e#:(559 j fi218-29?7 I US--vice Technician ❑Third-Party <br /> International Code Council Certification#: Expiration Date: <br /> I certify that, for the facility indicated at the top of this page.the individual(s) eel o -e will I <br /> serve as Designated UST Operator(s). The indiviaal(s) ul! ^n??dtFC` _ <br /> la .ill(` test .tions anal arnttal faCilitt' etttpla•.ee t.t itZit:��,ui aecouddl a;r- llt;l '� -�� ,.; <br /> - - _ =,�J! <br /> Re <br /> gulations, tit 1e 23,section 2715(c) - (f). <br /> R J0 , 1 <br /> ther more,I understand and am :n ifffa3l�i'ac�_cs^-`+itii �lte 3 eQiiireJ�l�illti 3>.aiu:cS, i <br /> tiSar4��•,_ <br /> ,. . r <br /> ! <br /> regulations, and local orclinancesl appheawe to untie g :�__ 3_lffagr s===�_-. _rati ; , )r`T <br /> li HEAO+ ,,iii,,._ ii <br /> NAIIE OF TANK OWNER(Please Print): X 17 <br /> .� 7 - <br /> SIGNATURE OF TANK OWNER: <br /> _-�• ! ';! - t i ln+:ER�S PI10NE l€: <br /> E � <br /> is `_OURC`ES C:tIN€-R-(-)L BOARD)BY JANUARY 1.2005.THE LOCAL AGENCY LIST IS AVAIL.ABIL <br /> 3T: lana�1 ai•��L't `��t�$.Cti.^.^\�'=5t^.^^t�C]r:L"J2—aevs.hinil. <br /> .:tP—AL Ur til!`c t."ASitrt,� IU f M3 _,v <br /> l.ii- T HE CY.ANGFr <br /> rCi it:tiiUcr vU� <br />