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woo•i;B-n mWi:d~i, gisti 'uoilewio}w ejow Joh �eNes:cel �e8ew r� _q❑ �(q penieow Senn xel siyl <br />0 \� <br />0 �" <br />Y � y <br />Owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of Compliance with UST Requirements <br />Designated UST Operatorts) fpr this Facility <br />FacilityName:Waterloo Liquors <br />Facility ID #: <br />Facility Address: 2512 E Waterloo Rd <br />Stockton: Ca <br />Reason for Submitting this Form (Check One) <br />X Change of Designated Operator <br />❑ Update Certificate Expiration Date <br />Facility Prone 2091163-4114 <br />PRIMARY ' <br />Designated Operator's Nam: James Flowers <br />Relation to UST FacHity (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician X Third -Party <br />Business Name (jfdIfferenrfrom above): Franzen -Hill Inc. <br />Designated Operator's Phone #: 559.972-5087 <br />International Cale Council Certification #: 8036233 -UC <br />Expiration Date: 1-26-13 <br />ALTERNATE 1 if0adonab <br />Designated Operator's Name. Josh Brown <br />Relation to UST Facility (Check One) <br />p Ouaer ❑ Operator ❑ Employee <br />Service Technician x Third Party <br />Business Name (VVjrerentfrom above) :Fnrmzen Hill <br />Designated Operator's Phone 559-688-2977 <br />International Code Council Certification# 8171810 -UC <br />Expiration Date: 10-22-14 <br />ALTERNATE 2 (OatfonaJ) <br />Designated Operator's Name: Adapt Taylor <br />Relation to UST Facility (Check One) <br />❑ Owner ❑ Operator ❑ Employee <br />X Service Technician XThird-Party <br />Business Name (Ifdoerentfromabove): Franzen -Hill <br />Designated Operator's Phone #: 559-688-2977 <br />International Code Council Certification#: 5311578 -UC <br />Expiration Date: 1-26-13 <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 individuals) 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 Print): <br />SIGNATURE OF TANK OWNER: <br />HATE: /p , z G l, Z/ 2 OWNER's PgoNE: s- G <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: rt���c.n�icrboartis.ca.Lorru�ncortrtctcupa_ac}s..ur : . <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />T,T.,..en t.. r 7nnn <br />Wd ££:ZVV Z10Z/trZ/01 :s}ea 111 :abed L£179£9V60Z :wad <br />