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AN <br /> Owner Statements of Designated Underground Storage Tank (UST) <br /> 46oe/ <br /> vj�®and Understanding of Compliance with UST Requirements <br /> Designated UST Onerator(s) for this Facility Nov 16 <br /> 201? <br /> AF- <br /> Ell► <br /> Facility Name:Express Market Facility ID#: PF MT <br /> Facility Address:419 S.Main Reason for Submitting this Form!(Che �Tl•/ <br /> Manteca,Ca 95337 X Change of Designated Operator 8 <br /> Facility Phone 209401-5292 ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-972-5087 X Service Technician X Third-Party <br /> International Code Council Certification#:8036233-UC Expiration Date: 1-26-13 <br /> ALTERNATE 1(Optionao <br /> Designated Operator's Name:Josh Brown Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above).-Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 559-688-2977 Service Technician x Third-Party <br /> International Code Council Certification#8171810-UC Expiration Date: 10-22-14 <br /> ALTERNATE 2 (Opgional) <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(Ifd fferent from above):Franzen Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-688-2977 X Service Technician XThird-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 u erground storage tanks. <br /> NAME OF TANK OWNER(Please Print): 13DU� ' /�/ <br /> SIGNATURE OF TANK OWNER: <br /> —4�2 <br /> DATE: OWNER'S PHONE#: U2, <br /> ,� Ej, <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: .,., ., .,.,., r;;.,.,,r;,..., , . <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> T�Tn.�nmhar�nnn <br />