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r <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />Designated UST Operator(s) for this Facility <br />Facility Name: Hammer I-5 AMIPM <br />Facility ID #: <br />Facility Address: 3250 W. Hammer Lane <br />Strockton Ca. , 95207 <br />Reason for Submitting this Form (Check One) <br />x Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Phone 209 662-4452 <br />PRIM®RV <br />Designated Operator's Name: James Flowers <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (If differentfrom above): Franzen -Hill Inc. <br />Designated Operator's Phone #: 559-972-5087 <br />International Code Council Certification #: 8036233 -UC <br />Expiration Date: 1-26-13 <br />®T.TF.RNATF. 1 /nndanah <br />Designated Operator's Name: Tyne Hardeman <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (Ifdierentfiom above):Franzen-Hill <br />Designated Operator's Phone 559-688-2977 <br />International Code Council Certification# 8131628 -UC <br />Expiration Date: 11-11-13 <br />-M, / s_, I <br />Designated Operator's Name: Adam Taylor <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (If differentfrom above): Franzen Hill <br />Designated Operator's Phone #: 559-688-2977 <br />International Code Council Certification#: 5311578 -UC <br />Expiration Date: 1-26-13 <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 <br />1 <br />PHONE #: foq ) P1 4— ( Z J <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: �4 \Z iv i�A�t' B6( (a V%17-IiiC3iC(De i6 �i_6 C// iil i'.l �G'i'C i766:i1, <br />AT -1- Inn/1 <br />