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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Designated UST OperatorLs <br /> I for this Fac <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 0 Change of Designated Operator <br /> Facility Phone (209)838-1546 0 Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):Franzen-Hill Inc. 0 Owner 0 Operator 0 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 I (Optional) <br /> Designated Operator's Name: Tov 3 Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Ilill 0 Owner 0 Operator 0 Employee <br /> 3 Service Technician (Third-PartyDesignated Operator's Phone#: 3 <br /> International Code Council Certification Expiration Date: 10 -01-�- I <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If different from above): 0 Owner 0 Operator 0 Employee <br /> Designated Operator's Phone#: 0 Service Technician OThird-Party <br /> International Code Council Certification#: Expiration Date: <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 /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> T-A www.waterboards.ca.gov/ust/dbiitacts/cupa agys.htmi. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />