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`01/11/2012 14:46 209474 1 HAMMER I5 ARCO PAGE 03/04 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />nghmted UST Onerator(s) for this Facility <br />Facility Name: HAIALMR 1-5 ARCO <br />Fatality ID #!: <br />Facility Address: 3250 W. HANNA ER. LANE STOCKTON, CA 95207 <br />Reason, for Subuuttin this Form (Check One) <br />❑ Change of Designated Operator <br />❑ Update Cartificate Expiration Date <br />Facility Phone <br />1?REVI&RX <br />Designated Operator's Name: <br />13usmass Name (Ifdifferent from above): Franzen --Hill Ine <br />Relatiatt to UST Faetlity (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Teclmiciaa X Tbitd-Patty <br />Designffied Operator's Phwe #: (559 Qf jZ-'" a <br />International Code Council Certification #: V C2 <br />Expiration Date � � • <br />ALTERNATE I( <br />Designated Operator's Name: Terry Hodson <br />Relation to UST Facility (Check One) <br />Business Name (Ifdierentfrom above): Franzen Hill <br />0 Owner Q Operaor 0 Employee <br />Designated Operator's Phone #: (559)68&2977 <br />X Service Tecbmitcian X Tbird-Party <br />International Code Council Certification #: 80214453 -LTC <br />Expire on Date: 02/25/2011 <br />ALTERNATE z ( <br />Designated Operator's Name: Stege Zcvahlen <br />Relation to UST Facility (Check One) <br />❑ Owner cl Operator ❑ Employee <br />XService Technician: X Third Party <br />Business Name (, f d;/ferent firom above): Franzen Hill <br />Designated Opm-ator's Pbone #: (559)689-2977 <br />International Code Council Certification#: 8025473 -VI <br />iE)q) tadon Date. 03/1212012 <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 naontwy <br />facility inspections and annual facility employee training, in accordance wi tb California Code of <br />Regulations, title 23, section 2715(c) - (1). <br />Furthermore, t understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER Mew <br />SIGNATURE OF TANK OWNER.- <br />]DATE: <br />WNER: <br />AA.TE: IZ./Z 1 / I <br />FHONA #: (Z ) 414-0112- .�j <br />/ 111341101WAXI 014011I# 1 1 1, t '1 I <br /># 1 f C 1 1 ; f 11 <br />F4'9— aut11.c_L.. '� _7 1_t R Jar t- tt- <br />r.T...,�. I� e f)nnn <br />