COMPLIANCE INFO_1999-2009 - Laserfiche WebLink

Home Browse Search

Owner Statements of Designated Underground Storage Tank (UST) Operator and Understanding of Compliance with UST Requirements Designated UST Operators) for this Facility Facility Name:Escalon Mini Mart Facility ID#: Facility Address: 1079 E.Yosemite,Escalon,CA.95320 Reason for Submitting this Form(Check One) ❑ Change of Designated Operator Facility Phone (209)838-1546 ❑ Update Certificate Expiration Date PRIMARY Designated Operator's Name:Tony Murch Relation to UST Facility(Check One) Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: (5 59) 688-2977 X Service Technician X Third-Party International Code Council Certification#: 8008380-UC Expiration Date:2/25/2011 ALTERNATE 1 (Optional) Designated Operator's Name:Terry Hodson Relation to UST Facility(Check One) Business Name(Ifdifferent from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#:(559)688-2977 X Service Technician XThird-Party International Code Council Certification#:8021463-UC Expiration Date: 8/22/2011 ALTERNATE 2 (Optional) Designated Operator's Name: Relation to UST Facility(Check One) Business Name(If different from above): ❑ Owner ❑ Operator ❑ Employee Designated Operator's Phone#: ❑Service Technician ❑Third-Party International Code Council Certification#: Expiration Date: I certify that, for the facility indicated at the top of this page,the individual(s) listed above will serve as Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections and annual facility employee training, in accordance with California Code of Regulations,title 23, section 2715(c) - (f). Furthermore,I understand and am in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Please Print): fy z W//V—J) J S/P�/I SIGNATURE OFTANK OWNER: DATE: 7 OWNER'S PHONE#: R—