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Owner Statements of Designated U-ndtiground Storage Tank (UST)Operator <br /> and Understanding of Compliance with US-r Requirements <br /> Facility Name:ESCALON NM41 MART Facifivy,ID 4- <br /> Facility Address: 1097 VOSFMITE AVENUE,ESCALOY,CA Reason for Subrnitting this Form rCheek G'ze.) <br /> Facility Phone o Change of Designated Open—tor <br /> Ei Update-Certificate Expiration Date <br /> PRIMARY <br /> r'sYat ame: Zra tef'--e—) t's,--e V Relation to U,,F FaciliN;(Check <br /> Busim-.-.s Name(1fdffieprnifrarn above):Franzen-Mill fnEl 0"Mcr 11 OparatoT 0 nploycc <br /> Designota0perator's.Phone#,-(559)688-2977 X Servace"fechnicizai x Thir—d.Pany <br /> Internationd Code-Councii Certific-atim r-19 3�<o 2-7 —U C ExpLrali on Da te—7 '� <br /> ALTERNATE,i nfiow4 <br /> Destpated Operztorl&Name-TaTy Hadwa Relation to UST Facility(Cheek ate) <br /> Business Name(If d!fferentfrom above).-Fmimen-11,11 0 Owmer 0 Operator to Fmployce <br /> lksignat&Opmalm's Phone N.-(559)688-2977 X SLnice Technician X"third-PxV <br /> hitemational Code Councff QcrtifivAim#:.8021-463-UC, Fxpiration Date: 01/2512411 <br /> ALTERNATE 2 (Opdond) <br /> Designated Orxrdor's Name:Steve Zivahlen Relation to UST Facility(Cl eck One) <br /> Dusin-cm NarncT(Ifdiffemritfrom 4; ove)-Frarasn4MJ a Ow-cr El Op-cra-toy Qj Employl:-- <br /> Designated Operator's Phone 9-.(559)688-2977 X-Sernce'lle--h,mcian X <br /> International Code Council Certification4:8025473-VI Expiration 1>te:03112/2012 <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 in-9netions-and annud f&6fq employee training,in accordance with California Code of <br /> Regulations,title 23-, section-2715{c}-(f� <br /> Furthermore, I understand and am in con, pliant e with the requirement-a (statutes, <br /> regulations, and local ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWN-ER(Plime Print): 13'�4,j /V <br /> SIGNATURE OF TANK OWNER: <br /> DA-TE- OWNER'S PHONE M. c'�O 00-3) ,� <br /> NOTE:1)SUBMIT TEO COMPLETED FORM TO THE LOCAL AGENCY(INOTA, THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,200:5.7t HE LOCAL AGENCY IDIS T IS AVAaABLE <br /> AT.www.Avatcrboards.c&wv/uWcontactdcuna aevs.hunf. <br /> 'GES TO THIS'INFORMATION VVrrEIN DA <br /> NOITIFY.TBELOCAL AGENCY OYANY CHAA 39 TS' <br /> -' 0 <br /> F.THE C GE.: <br />