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Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />Facility Name: <br />Facility ID #: <br />Facility Address: �3zsc� <br />C j '` <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />13Update Certificate Expiration Date <br />Facility Phone X359) Z'Z,,; <br />Designated UST Operator(s) for this Facility <br />PRIMARY <br />Designated Operator's Name: Chris Deyoung <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (If different from above): Franzen -Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />International Code Council Certification #: <br />Expiration Date: <br />Ai.TF.RNATF.I /Ontional) <br />Designated Operator's Name: Tyne Hardeman <br />Relation to UST Facility (Check One) <br />❑ Owner Q Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (If different from above): Franzen -Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />International Code Council Certification #: 8131628 -UC <br />Expiration Date: 11/11/13 <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): Franzen -Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <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. <br />NAME OF TANK OWNER (Please <br />DATE: - JZ./2-1 Z11 <br />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: www.waterboards.ca.sov/ust%contacts/cupa agvs.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />