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Owner Statements of Designated Underground Storage Tank(TJST) Opemtor <br /> and Underst&ndiag of Compliance with UST RequirrernenLq <br /> Designated LTST Overator(s)for this Facilk <br /> Facility N e,Escalon gni Marl: Facility lD4- <br /> Fwillly Addrem, 1097 E,Yuszenmie Reason'forSubmittinZ thi, ,v.r om(Check One) <br /> Escalon,CA 0 Change of DeSjgRa1_,Cj OpCrator <br /> FacilityPhone (209)83-3-1546 0 UPdate Certif,2!t;Expiration Datc__ <br /> P <br /> Dcsignated Operator's hrame;Tony Murch Relation to LIST Fility(CAccl: <br /> t <br /> Busimss NuneFranzen-Hill Inc. 0 Ommcr 0 Opwator 0 Employee <br /> Designated Operator's Phme 0;(5-59)6-38-2977 X serviocTechniclan X Third, <br /> lAtemational Code Council Cem-Ocation*P 800831MS -M Expiratiot Datc:2,'25/201 <br /> ALTS NATE I LQjpg&qQ <br /> DwRignated Operator's N=e:Tea- <br /> y Hudson Relation to UST Facility(Chec*Oma) <br /> HUSAnW.Narn-C(11dijOire-nifrom ahaw):Fromen-Hill 0 Owncr 0 Opemtw 0 F�mploycc <br /> Designated 0M,&toT'_-,Phone#-(554)689,7977 X Service Technician XTiiird-Pany <br /> International Cods Council Catiflication 4,8021463-UC I Expiration Date: <br /> ALTERNATE I (Wand) <br /> Designatcd Opmtor's Name: Reliftion to UST Facility(Check <br /> Business Name(ydiern ifrom above), 0 Owner 0 09cm- tar 0 Employee <br /> _6rAV=ed Operator',Phone#-, . ....... OServim Technician onurd.pary <br /> Code Cmmij P-mific ExpiTation Date: <br /> ,I certify that, for the fac-dity indicated at the tOP Of this Page,the individual(s)listed above will <br /> serve as Desipated UST Operator(s). Thc individual' � vAll cionduct and docuMent 1p nt y <br /> ks) .0 b! <br /> facility inspections and anniW facility employee-training, in accordance With California Code of <br /> Regulations,title 23, s� ion 2715(c)- <br /> Furthermore,I understand and a . ' compliance vitis the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground storage tanks. <br /> r_7ile I <br /> NAME OF TANK OWNER(Plme Print)® sr^/ n <br /> r <br /> SIGNATURE OF TANK OWNER: <br /> r% <br /> DATE-, J_- iER,S PHONE ff; <br /> NOTE: 1)STJ15MIT THIS COMPLETED FOR1M TO TFIE LOCAL AGENCY(NOT 1HE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1i 21M.THE LOCAL AGENCY LIST Is AVATILABLE <br /> AT-. www.watirb 29ird,, ca v/ust/qvn_t_aCU <br /> 2)NOTVIV THE LOCAL AGENCY OF ANY CHANGES TO THIS Il`FOR wrrHIN 30 DAYS <br /> OF THE CHANCE <br /> Navernha 2034 <br />