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HLUENED <br /> MAY 15 2013 <br /> Owner Statements of Designated Underground Storage Tank (US". �OQOUNTY "`' <br /> g e EN RONMENTAL <br /> and Understanding Of COI11 ?Iia11Ce with LIST RegUlrellle ,LTH DEPARTMENT <br /> U <br /> Designated UST Operators)for this Facility <br /> Facility Name:EXPRESS MARKET Facility ID#: <br /> Facility Address: 419 S MAIN STREET,MANTECA,CA 95337Reason for Submitting this Fort.(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone:209-239-7978 ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:Lyle Meeks Relation to UST Facility(Check One) <br /> Business Name(1f dIerent from above);Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> i <br /> Designated Operator's Phone#:(559) 805-3367 x Service Technician x Third-Party <br /> International Code Council Certification#:8188753-UC Expiration Date:01/18/2015 <br /> ALTERNATE l(Optional) <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(1f doerent from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(554)972-5087 ❑Service Technician ❑Third-Party <br /> International Code Council Certification#:8036233-UC I Expiration Date: 01/12/2015 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(Ifdi,(jerent from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 []Service Technician ❑Third-Party <br /> International Code Council Certification#:8I43455-UC Expiration Date:01/02//2015 <br /> I certify that, for the facility indicated at the top of is page,the individual(s)listed above will <br /> serve as Designated UST Operator(s). The individu A(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 compliancf with the requirements(statutes, <br /> regulations, and local ordinances) applicable to underground storage tanks. <br /> i <br /> NAME OF TANK OWNER(Please Print): UL-1I % 5_� //lid-P-2 4 — <br /> SIGNATURE OF TANK OWNER: <br /> DATE: _ f�C3J OWNER'S PHO E#: 0( qz- <br /> I <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE fLOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT:www.waterboards.ca.gov/ust/contacts/cups ages html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES,11O THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. j <br /> November 2004 <br />