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0 0 <br /> Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> ® and Understanding of Compliance with UST Requirements <br /> Designated UST Oierator(s)for this Facility <br /> Facility Name:LATHROP SHELL Facility ID#: <br /> Facility Address: 16500 S.HARLAN Reason for Submitting this Form(Check One) <br /> ❑ Change of Designated Operator <br /> Facility Phone ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentftom above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 % Service Technician % Third-Party <br /> International Code Council Certification#: Expiration Date <br /> ALTERNATE 1 nal <br /> Designated Operator's Name:Terry Hodson Relation to UST Facility(Check One) <br /> Business Name(Ifdifferent from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 X Service Technician XThird-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 /> Designated Operator's Phone#:(559)588-2977 XService Technician X7Third-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 to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Z-/-c <br /> SIGNATURE OF TANK OWNER: <br /> DATE: Z/7/P i/ OWNER'S PHONE#: (meq/ 5'— T6 s 5 <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:www.waterboards.ca.gov/ust/contacts/cupa agys.htm]. <br /> it2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />