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w <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Desi2nated UST Operator(s) for this Facility <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 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(Ifdii erenl 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 boreal) <br /> Designated Operator's Name:Matt Cheney Relation to UST Facility(Check One) <br /> Business Name(If dierent from above):Franzen-hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone 559-688-2977 X Service Technician x "Third-Party <br /> International Code Council Certification#8032270-UC Expiration Date: 1-13-I3 <br /> ALTE ATE 2 (Optional) <br /> Designated Operator's Name: Adatn Taylor Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Plione#: 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 Print): <br /> SIGNATURE OF TANK OWNER: <br /> DATE: OWNER'S PHONE#: <br /> NOTE: 1)SUBMIT THIS 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: Isa/P�l'ilusjif'`111 14;i,-111vA—Aov, Iia;,:: <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OFT E CHANGE. <br /> 1 <br /> NT--l-,10(1/1 <br />