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01107f2011 15:53 5596881467 FRANZEN HILL PAGE 01102 <br /> JAN 07 2011 <br /> Owner Statements of Designated Underground Storage'Wank (UST) Operator ,N-i-; <br /> and Understanding of Compliance with UST Requirement ' . <br /> Facility Name:Eeono Gas Facility ID#: <br /> Facility Address: 880 Victor Rd. Reason for Submitting this l+onm(Check One) <br /> .Lodi,CA. ❑ Changc of]Designated Operator <br /> Facility Phone ❑ Update Certificate Expiration Vate <br /> Designated UST Operator(sl for this Facility <br /> PRIMARY <br /> Designated Operator's Name:David Martin, Relation to UST Facility(Check One) <br /> Business Name(Lf ddireat fmm above):Franzen-llill Tne. ❑ Owner ❑ Opm*or ❑ Employee <br /> rnsignated operator's Phornc#:(559)688-2977 x Servicc Twhnician I Third-Party <br /> intctnationsi Code Council Certification 4:5246124-UC Expiration Date: 10/3112011 <br /> ALTERNATE <br /> DesignatedOperator's Name: Excquiei(Jr.)Sinco Relation to UST Facility(Check One) <br /> Business Name(If alr,/femni from arbow):Franzen-Ml T.0c. ❑ Owner ❑ Operator ❑ Employee <br /> besignated Operator's Phone#:(559)688-2977 13 Service Technician ❑Third-Party <br /> International Code Council Certification 4:5302739-UC Expiration Date: 12/12/2010 <br /> ALTERNATE 2 (OPdONAP <br /> Designated Operator's Name:Gary.R,ummerfield Relation to UST Facility(Check One) <br /> Business Name(If&fferentfrtam above):Franzen-Hill Inc, a Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 ❑Service Technician ❑Third-Party <br /> International Code Council Certification#:5246331-UC Expiration Datc:11/01/2011 <br /> 1 cerkify 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 trainin& 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 an erground storage tanks. <br /> .NAME OF TANK OWNER(Please Princt). <br /> SIGNA'T'URE OF TANK OWNER:( <br /> .DATE: °fZ` _ 19 t:3 v OWNER'S PH NE 8 — J -7Z4 <br /> r <br /> NOTE: 1)SUBMIT THUS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005.THE LOCAL AGENCY LIST 15.AVAILABLE <br /> AT:www.waterboards.cae ez�_v_/_u,%—VcQrtt-gctfiL g�- <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THISINFORMATION WITMN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br />