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• "01/11/2012 14:46 2094749 1 HAMMER I5 ARCO PAGE 04/04 <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />Facility Name: POA <br />Facility ID #: <br />Facility Address: -Z ` _ � t,.S_ <br />CI z.(51 <br />Reason for Submitting this Form (Check One) <br />x Change of Designated Operator <br />❑ Update Certificate Expiration Twe <br />Facility phone '{559) 7 z <br />Designated UST Operator(s) for this Facility <br />W01MA A DV <br />Designated Operator's Nkne: Cbris Ueyoung <br />Relation to UST Facility (Check One) <br />o Owner ❑ Operator ❑ Employee <br />X Service Technician x Third-Paity <br />..Business Name (Ifdii j"erent from above): FralMen-Hill Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />tntenational Code Council Certification #: <br />I Expiration Date: <br />A t TrDW A Tip" Y 11)­4.. <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 (ydi fferent from above); Franzeu-Mil Inc_ <br />Designated Operator's'Phone #: (559) 688-2977 <br />International Code Council Certification #: 8131628 -UC <br />I Expiration Date: 11/11/13 <br />AT.W..RNAW 1, /nnvinnah <br />Designated Operator's Name: <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />❑service Tcchniciaa ❑Third -Parry <br />1Businoss Name (If different from above): Franzen -Hili Inc. <br />Designated Operator's Phone #: (559) 688-2977 <br />In Iernational 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 />servile as Designated LIST 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 />SIGNATURE OF TANK OWNER: <br />DATE: l 2_ l Z1 ! <br />'S PHONE #: <br />NOTE: I) 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: wAi.Nyaterboards.ca.p-ov/ust/contacts/cui)a. as�•s.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THF CHANGE. <br />November 2004 <br />