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Owner Statements�Designated Underground Storag�,ank (UST) Operator <br />and UndersLanding of and Compliance with UST Requirements <br />Facility Name: Flame Mini Mart <br />Facility ID #: r R o D 0o 3,7p <br />Facility Address: 1301 West Kettlemen Lane, Lodi CA 95242 <br />Reason for Submitting this Form (Check One) <br />�] Change of DesiglnIated Operator <br />❑ Update Certs ,te-E8pir)ltion Date <br />Facility Phone #: (209) 334-3233 <br />Designated UST Onerator(s) for this Facility, p E C 14 2004 <br />PRIMARY <br />Designated Operator's Name: Ron Draper <br />Relation to UST kfk,�e <br />10!k' <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician X Third -Party <br />Business Name (If different from above): PETROLEUM ENGINEERING, INC. <br />Designated Operator's Phone #: (800) 505-3588 <br />International Code Council Certification #: 5243734 -UC <br />Expiration Date: 10/26/06 <br />ALTERNATE 1 (Optional) <br />Designaied Operator's Name: Brian Burns <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician XI Third -Party <br />Business Name (If different from above): PETROLEUM ENGINEERING, INC. <br />Designated Operator's Phone #: (800) 505-3588 <br />International Code Council Certification #: 5240729 -UC <br />Expiration Date: 08/25/04 <br />ALTERNATE 2 (Optional) <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑ Service Technician ❑ Third -Party <br />Business Name (If different from above): <br />Designated Operator's Phone #: <br />International Code Council Certification #: <br />Expiration Date: <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.. l <br />NAME OF TANK OWNER (Please Print): l!%ili ��,,� Gr f AfN 3 fr • / PZ -44 l F" 4 <br />SIGNATURE OF TANK OWNER: �_066_lz <br />DATE: 12 -) 3 - ,�9 rI <br />OWNER'S PHONE #:1a o5) 3 3 y-3 X 3 3 <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE <br />STATE WATER RESOURCES CONTROL BOARD) BY JANUARY 1, 2005. THE <br />LOCAL AGENCY LIST IS AVAILABLE AT: <br />www.waterboards.ca.gov/ust/contacts/cupa a , s.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION <br />WITHIN 30 DAYS OF THE CHANGE. <br />November 2004 <br />M;., mod <br />