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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Desi na ed UST Operator(s)for this Facili <br /> Facili Name: <br /> ty I Facility ID#: <br /> Facility Address: Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone: ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Nan ie:Lyle Meeks 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)805 3367 X Service Technician X Third-Party <br /> International Code Councili Certification#:8188753-UC Expiration Date:01/18/2015 <br /> ALTERNATE 1 O tiona# <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If different f om above):Fra en-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)972-5087 ❑Service Technician ❑Third-Party <br /> International Code Council!Certification#:8036233-UC Expiration Date: 01/12/2015 <br /> ALTERNATE 2 (Options#) <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(Ifdifferenifrom above):Frc nzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 ❑Service Technician ❑Third-Party <br /> International Code CouncilCertification#:8143455-UC Expiration Date:01/02//2015 <br /> I certify that, for the facility indic ted 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 Pi int): `vL <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: �Q �y���--C 2. <br /> t t <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:www.waterboards.c6.izov/ust/contacts/cupa agys.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />