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0 From: Franzen-Hill I.. To:19166537239 Page:214 Date: 1012:, 1210:48:03 AM <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: FCCt,,,0 &?As Facility ID t/: <br /> Facility Address: S$o F V i cTd)Z JZ4 LoDi CA q!5p Reason for Submitting this Form(Check One) <br /> fiY Change of Designated Operator <br /> Facility Phone 2-09-34q — ori5& ❑ Update Certificate Expiration Date <br /> PRIMARY <br /> Designated Operator's Name:Mathew Cheney Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 x Service Technician x Third-Party <br /> International Code Council Certification#:8032270-UC Expiration Date:01/18/2013 <br /> ALTERNATE 1 tion <br /> Designated Operator's Name:James Flowers Relation to UST Facility(Check One) <br /> Business Name(If difj'erentfromabove):FranzenHill ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:(559)688-2977 ❑Service Technician ❑'third-Party <br /> International Code Council Certification#:8036233-UC Expiration Date: 03/01/2013 <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:Adam Taylor Relation to UST Facility(Check One) <br /> Business Name(If different from above):Franzen-Hill ❑ Owner ❑ Operator ❑ Employee <br /> ...................._.....-._......_...— ---- ... —.._...-- _..........._........_....._...... <br /> .._. <br /> Designated Operator's Phone#:(559)688-2977 ❑Service Technician ❑Third-Party <br /> International Code Council Certification#:5311578-UC Expiration Date:01/11/2013 <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, l 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 Print): A"J' .PAR WA <br /> SIGNATURE OF TANK OWNER: s <br /> DATE:�t 2 x111'2— OWNER'S PHONE#: (TU _411--492, 9 <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.gov/ust/contacts/cgp4 ?t4vs html. <br /> 2)NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> This fax was sent with GFI FAXmaker fax server. For more information,visit http://www.gfi.com <br />