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Owner Statements of Designated UndergroundStorage T (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> esi ate a s)fort is Facilitv <br /> Facility Name:ESCALON MM MART Facility ID#: <br /> Facility Address: 1097 YOSEN11TE AVENUE,ESCALON,CA Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone ❑ Update Certificate Expiration Date <br /> PREAARY <br /> DesignatedOperator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> DesignatedOperator's Phone#:(559) 688-2977 x Service Technician % Third-Party <br /> International Code Council Certification#: Expiration Date <br /> ALTERNATE tO do <br /> Designated Operator's Name:Terry Hodson Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above).-Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> DesignatedOperator's Phone#:(559)688-2977 X Service Technician X Third-Party <br /> International Code Council Certification :8021463-UC Expiration Date: 02/25/2011 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Steve Zwahlen Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above):Franzen Hill ❑ Owner ❑ Operator ❑ Employee <br /> DesignatedOperator's Phone#:(559)688-2977 XService Technician X Third-Party <br /> International Code Council Certification#:8025473-VI Expiration Date:03/12/2012 <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 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 <br /> >>o underground <br /> storage tanks. <br /> NAME OF TANK OWNER(Please Print): /" <br /> SIGNATURE OF TANK OWNER: <br /> ATE: 1 - l / OWNER'S PHONE : 0 S - <br /> NOTE: 1)SUBMIT THIS COMPLETEDFORM TO THE LOCAL AGENCY T THE STATE WATER <br /> RESOURCES CONTROL )BY JANUARY 1,2005.THE LOCAL AGENCY AVAILABLE <br /> AT: «-i,.-%,,T.waterbeards.ca ov/ust/contacts/cupa a 's.htnil. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> F THE CHANGE. <br /> xfn-1—onnn <br />