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0 0 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Facility iV Facility ID <br /> Facility Address: t Reason for Submitting this Form(Check One) <br /> ZA x Change of Designated Operator <br /> 1 La Update CertifwateExp'rafion Date Facility Phone f" <br /> Desiggated UST Overator(s)for this,Facility <br /> PRINURY <br /> Designated opemor's Name- Chris eyoung Relation to UST Facility(Check One) <br /> Business Name(1fd[fferentfrom above):Franzen-E'II Inc. 0 owner a operator 0 Employcc <br /> Designated Operator's Phone#:(559)688-2977 X Service Technician x Third-Party <br /> International Code Council Certification Expiration Date- <br /> I— <br /> ALTERNATE I LOgftal) <br /> Designated Operator's Name: Tyne Han Relation to UST Facility(Check One) <br /> Business Name qfd(prenifrom above):Franzen-Hill Inc. D Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#:(5 9)68&2977 X Service Technician X Third-Party <br /> International Code Council Certification#: 8131628-UC Expiration Date; 11/11/13 <br /> ALTERNATE 2 (Option ) <br /> Designated Operator's Name,. Relation to UST Facility(Check One) <br /> Business Name Qfdifferenifrom above):Franzen-Hill Inc. 0 Owner o Operator o Employee <br /> Designated Operator's Phone#:(559)688-2977 OService Technician---OThird-party <br /> International Co&Council Certification#: Expiration Date: <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): to f*'o Atl <br /> SIGNATURE OF TANK OWINER: <br /> DATE: <br /> NE WS PHONE#: <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE AL AGEING'(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE ALA LIST IS AVAILABLE <br /> AT.-,.vw-tv.waterbowds.ca.wvlu,sticontactsLcm Ms.html, <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Nnvember2OM <br />