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8 <br /> e <br /> Owner Statements of Designated Underground Storage Ta r t 12 <br /> and Understanding of Compliance with UST Requirements <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 ❑ Change of Designated Opgator <br /> Facility Phone 209-838-1546 ❑ Update Certificate Expiration Date <br /> I)esinated UST ®perator(s) for this Facilitv <br /> PRIMARY <br /> Designated Operator's Name: David Martin Relation to UST Facility(Check One) <br /> Business Name(Ifdiiferent from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559) 688-2977 X Service Technician X Third-Party <br /> hnternational Code Council Certification#: 5246124-UC Expiration Date: 10/31/2011 <br /> ALTERNATE 1 O bona <br /> Designated Operator's Name: Exequiel(Jr.)Sinco Relation to UST Facility(Check One) <br /> Business Name(If different front above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559) 688-2977 XService Technician XThir'd-Parry <br /> International Code Council Certification#:5246152-UC Expiration Date: 11-12-12 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Gary Rumnterfield Relation to UST Facility(Check One) <br /> Business Name(If different front above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559) 688-2977 XService Technician XThird-Party <br /> International Code Council Certification#:5246331-UC Expiration Date: 1-20-13 <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 27I5(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 /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT TIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> SOURCES CONTROL BOARD)BY JANUARY 1,2005. THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT: ::1\'�L.A01®1't1frD;11'/�9 1-10 II US !®!\71 C.,M SIC"!pa—a,".S {.....1 <br /> / <br />