Laserfiche WebLink
0 <br /> Owner Statements of Designated Underground Storage Tank.(UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Des' ated UST Ogerator(s)for this Facility <br /> Facility Name:QUICK N SAVE Facility ID#: <br /> Facility Address:1901 S.EL DORADO Reason for Submitting this Form(Check One) <br /> STOCKTON CA,95206 ❑ Change of Designated Operator <br /> Facility Phone (209)948-2619 ❑ Update Certificate Expiration Date <br /> PROMRY <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:559-972-5087 X Service'rechnician X Third-Party- <br /> International <br /> hird-PartyInternational Code Council Certification#:8036233-UC Expiration Date: 1-26-13 <br /> ALTERNATE 1 ftdonal <br /> Designated Operator's Name: Relation to UST Facility(Check One) <br /> Business Name(If differentfrom above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: Service Technician Third-Party <br /> International Code Council Certification Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Relation to'UST Facility(Check One) <br /> Business Name(Ifdifferent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: ❑Service Technician ❑Third-Party <br /> International Code Council Certification#: Expiration Bate: <br /> 1 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): O L <br /> SIGNATURE OF TANK OWNER: <br /> DATE:0 1 — // OWNER'S PHONE#: '1- 6 6 2– <br /> �11< 7 <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.html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />