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01/20/2011 14:29 5596881 '-' FRANZEN HILL PAGE 02/02 <br /> �.� U103.1fi-MMMI/A 'U04PuLOM*low ro j uzougs xq JoNawXy-q I j*3Ala-Jar spM%S1 S1141 <br /> 94//9/2018 15:50 5596BBia67 FRANZEN HXL JAN I PT 11 06/06 <br /> Owner Statments of Desipated Undcrgrowid Storage Tanis(LIST) Operator <br /> and Understanding of COttlpiiancewith UST Requirements <br /> )RAO er NSO USSSttou :$)for Wk F:aitit„1; <br /> Faaltgi!Mohr,Lathrop Shall 173011rly II?! <br /> rpcifity Address; 165IJ0$,Iierlpa R88=for$ubrnin:ng this Form(Check Dna) <br /> Gatnm%CA W Chanse of Dmi gnoted Op=cor <br /> I 63e111ey Phone 9A9)403-39590 0-On R Psi 3 S a u Lbitificste ex iratiannate <br /> DMJkRY <br /> Uu4nawd Opero or's Name:Ttxty'Murch Relation to UST Facility(Chick One) <br /> aUmirtm Natrtc(D'Ifi fersruIkom ahove}:l:fa Wn-MilI I n M o Owner ❑ Opacatm o Eripinycr <br /> Deeipated Qpr mor's Ilmne S:(559)699-2477 x Sc"i"Teshn;cisn x zi, o-party <br /> tnternadoud Cade Council CMtsewen 4:9008380-UC F.xPblooet vdm:2/25n011 <br /> ALTERNATE re <br /> Daslan imcd Opeeeu W A Name:Terry Mwixoa Rdaiott to UST Fac,'[iv(Check N4 <br /> 8usinenName(Ifd4pre"11Mts j.Fim,.-en.t{t!1 C Owner a opomm q Employee <br /> 005noICAU09ratoritPIMCA:(339W3-2977 XSaMceTechcacian xnlyd-party <br /> Int+MIdenal C04C CUUM11 Cenificalion e:3011463-UC ixOra itm Date: <br /> ALTIERMATE 2 sp—da <br /> Designated OVc macs game Melon to UST Faciltty(Cheek One) <br /> ausir1esName(ItAfo.errrfromO&OMO. O Owner D Opa*w C Gmpioyes <br /> Desl¢mcued OveratoetTbonciif, OSaviecTechnicim =hirdrPmty <br /> Intertotanat Code Council Certificaatlen4: axpirsdan <br /> 1 certify that,for the facility iadicaWd at doe top of this page,the individual(k)listed above will <br /> serve as I3csigt>latcd UST Operdor(s). The individua(s)wilt oauduet and document=Athl y <br /> facility inVmctions and arlrlval facility cWP1oyec training,in=Ordance-with California Code of <br /> Rcgtdationa,tine 23,sead*tz 2715{c)-(f), <br /> Furthermore,I undt imsind and am In cnfrlpHance with the reclgJrem tl:ta(statutes, <br /> regulations,and local Ordinances)eppticable to uadeWound storage tanks. <br /> MANrit OF TANK OWlYLR(Pluse Prime)*. .r/_ T_�,_1. . � _�' <br /> s <br /> SiGIVATURF.O TANX OW14EX: 3 <br /> TfA'l'E: 2d f ,OWNER'S PnoprE Al,(Za q I 4a ?,r,3.$ za_�...� <br /> NOTE:1)SUNMrF TMCOlr LETED iFORMTO TRE LOCAL AGENCY(NOT TIN M RTAT'E WATVit <br /> RESOURCES{COMMOL FOAM)DY JAMU,ARY 1,2005.THE LOCAL ACag4c:y LIST IS AVAILABLE <br /> AT:www.welerlj3ands�ca�. � taltuna aav+.htmL <br /> 2)Dt'O'nTY TH8 LOCAL ACENCY OF ANY C"AcMCES TO TRIS WMRMAT7ON WA'TMM 30 DAYS <br /> A1F'1i"FrE CEIANGE. <br /> 140V*Mbcr 2004 <br /> rld 69-'W:S 0 LOM L/t•:041100 B2:e6ed 979=LV60z.ut01 j <br />