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REGEIVED <br /> Owner Statements of Designated Underground Storage Tank (UST) OPBRailof 2012 <br /> and Understanding of Compliance with UST Requirements <br /> TY <br /> Designated UST Operators)for this Facility E JORONME AQUIN Ai <br /> HEALTH DEPARTMENT <br /> Facility Name:Escalon Mini Mart Facility ID#: <br /> Facility Address: 1097 E.Yosemite Reason for Submitting this Form(Check One) <br /> Escalon Ca 95320 X Change of Designated Operator <br /> Facility Phone 209-838-1546 ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If dierent from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-972-5087 X Service Technician X Third-Party <br /> International Code Council Certification#:8036233-UC Expiration Date: 1-26-13 <br /> ALTERNATE 1 O do <br /> Designated Operator's Name:Josh Brown Relation to UST Facility(Check One) <br /> Business Name(Ifdierentfrom above).-Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 559-688-2977 Service Technician x Third-Party <br /> International Code Council Certification#8171810-UC Expiration Date: 10-22-14 <br /> ALTERNATE 2 ( <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):Franzen Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-688-2977 X Service Technician XThird-Party <br /> International Code Council Certification#:5311578-UC Expiration Date: 1-26-13 <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 Prat): /-?*C CVI YYD � y <br /> SIGNATURE OF TANK OWNER: a"`_ l <br /> DATE: 40 OWNER'S PHONE#: o �' 's ,- <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: v1�F�1".tG'#IC!"OO�si'C1S.C8.���'/ilSt%COtll�iCtS1CUt��3 �2L�'S_i;t _.. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> ATnwrumhar 7nnn <br />