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i <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Facility Name: N a. r Facility ID#: <br /> Facility Address: i e '7 6 ye g!�- Reason for Submitting this Form(Check One) <br /> ESC l41.orO e-,4. ❑ Change of Designated Operator <br /> Facility Phone 6- ❑ Update Certificate Expiration Date <br /> Designated UST Operators)for this Facility <br /> PRIMARY <br /> Designated Operator's Name:JOSH BROWN Relation to UST Facility(Check One) <br /> Business Name(If digerent from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated operator's Phone#:(559)688-2977 g Service Technician z Third-Party <br /> International Code Council Certification#:8171810 Expiration Date: 10/22/2014 <br /> ALTERNATE 1 <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Ope'rator's bone#:(559)688-2977 ❑Service Technician ❑Third-Party <br /> International Code Council Certification#: Expiration Date: 12/12/2010 <br /> ALTS ATE 2 <br /> Desi is Name: Relation to UST Facility(Check One) <br /> '�. Business Name(Ifdifferent from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 ❑Service Technician ❑Third Party <br /> International Corse Council Certification#: Expiration Dane: 11/01/2011 <br /> i <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 underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): <br /> SIGNATUQR�E OF TANK OWNER: <br /> Mckitiv <br /> DATE: ( v OWNER'S PHONE#' <br /> JAN 0 9 2014 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY qLMWftTft.,1.rAL <br /> --� AT:R,%w.waterbm&.cagov/ust/contacts/cupa g&s.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> AT~omhor 7nnn <br />