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Dec 23 04 09: 31a F- nnzen Hill 559cJ81467 p. 3 <br /> From: unknown Page:2/5 Date: 12/23/2004 8:12:09 AM <br /> uuv LJ LVVI ••.v 'JVLI +.•'• � VVL <br /> Dec 22 04 03:59P Franzen Hill 5596881467 p.2 <br /> I <br /> 1 <br /> I • <br /> j San Joaquin Co" <br /> !I Environmental Health DeparMent <br /> 304 F. Weber Ave,,Third Floor Stockton CA 95202 <br /> 7 Telephone(209)468-3420 Fax(209)468-3433 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and UnderStandiug of and Compliance with UST Requirements <br /> )=ICAIyNamr. Food 4 Less Facility mH: N-4608 <br /> FacdityAddrms:3408 Manthey St_ Reasoafor Submittingthis Form(CheokOne) <br /> Stockton, CA X ChangaofDesignmedOperator <br /> Facility Phone b; 2 - 1 ❑ Update:Ccrtiflcatx Expiration Date <br /> I <br /> Designated UST Operator(s)for this Facility <br /> PRIMARY <br /> Dctienattdoperator's Name: Franzen-Hill R.eladontoUST Facility(Cheat one) <br /> Easiness Namr(Ifdifjererafromabvw): ❑ Owner D operator ❑ Emplaym <br /> 0esignated0paatorsPhone9: 559 688-2977 ul ServiccTeehnician X Thitd•Party <br /> lntematlorial Code Council CcrtiFcatioe N: 5246124-LI Expiration Date; 11-19-06 <br /> ALTEiLVATE I Banal <br /> Dasignuod Opclator's Name: kelmicn to UST Facility(Cheet One) <br /> Business Name(Ifdi fererrfrom abvva): ❑ Owner O Operator p Employee <br /> DesignatcdOpcn►6or'sPhornb: ❑ Servicer—Mician ❑ Third-Parry <br /> International Code Council Cersificafion 4: Expiration D.tr- <br /> ALTERNATE 2 (Optional) t <br /> Designated Operator's Name, Relation to UST Facility(Cluck Ona) <br /> Busi-c"Namc(lfdfcrewfromabove): ❑ Owner ❑ Operator ❑ Employee <br /> Desienatcd Oparator's Phone 4: ❑ Service 7cchnician D Third-Party <br /> International Code Council Certification''k: Expiration Late: <br /> NOTE:TBX LOCAL RI GCLTLATORY AGENCY MUST 13E NOTIFIED OF ANY CHANGES TO THIS <br /> INFORMATION WITRUN 30 DAYS OF THE CHANGE. <br /> I <br /> i <br /> r <br /> I certify that,for the facility indicated at the top of this page,the individuaI(s)listed above will <br /> serve as Designated UST Operator(s). The indiiridual(s)will conduot and document monthly <br /> facility inspections and annual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 2715(e)-(f). <br /> i Furthermore,X understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances)applicable to underground st a tanks. <br /> NANIIu OF TANK owNF_R(please Pttot): <br /> SICr1�ATUTZI;OF TANK OVVNER: <br /> llATE: 1' ,23 -d OWNF-RIs PJ40-,T#: �� � 4SK —c�to I u 3 I <br /> This fax was received by GFI FAXmaker fax server. For more information,visit http:/lwwtw.gfi.com <br />