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Rp 05 10 08:40a p.3 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />Facility Name: Waterloo Liquors Facility H)#: <br />Facility Address: 2512 Waterloo Reason for Submitting this Form (Check One) <br />Stockton, CA ❑ Change of Designated Operator <br />Facility Phone (559) ❑ Update Certificate Expiration Date <br />Designated UST Oneratorfsfor this Facility <br />PRIMARY <br />Designated Operators Name: David Martin <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />g Service Technician x Third -Party <br />Business Name (Ifdiereni from above): Franzen -Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />International Code Council Certification #: 5246124 -UC <br />Expiration Date: 10131/2011 <br />AL7`1@ "ATE 1 V atonaa <br />Designated Operator's Name: Exequiel (Jr.) Sinco <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />E] Service Technician ❑Third -Parry <br />Business Name (If different from above): Franzen -Hill Inc. <br />Designated Operator's Phone #: (5 59) 688-2977 <br />International Code Council Certification #: 5302739 -UC <br />Expiration Date: 12/12/20 10 <br />ATE 2 (Dpii—D <br />Designated Operator's Name: Gary Rutnmerfield <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑Service Technician ❑Third -Party <br />Business Name (1fdlfferent from above): Franzen -Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />International Code Council Certification#: 5246331 -UC <br />Expiration Date: 11/01/2011 <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: 2� �� <br />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 />AT: a,xvw waterboards ca goy/usUcontactslcupa aevs.htinh <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />