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Owner Statements of Designated Underground Storage Tank (UST) Operator <br /> and Understanding of Compliance with UST Requirements <br /> Designated UST Onerator(s) for this Facility <br /> Facility Name: FedEx Ground Facility ID # : 953 <br /> Facility Address: 5655 Hood Way Reason for Submitting this Form (Check One) <br /> Tracy, CA 95377 ' Change of Designated Operator <br /> Facility Phone: 209439-2000 ❑ Update Certificate Expiration Dale <br /> PRIMARY <br /> Designated Operator's Name: David Turner Relation to UST Facility (Check One) <br /> Business Name Q(dii erentfrom above): Franzen- Hill Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone # : (559) 68 &2977 ' Service Technician ❑ lliird-Party <br /> International Code Council Certification # : 878865OUC Expiration Date : 9/8/ 18 <br /> ALTERNATE. 1 O lional <br /> Designated Operator's Name : Relation to USl' Facility ( Check One) <br /> Business Name (/f dierent from above) : ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator' s Phone #: ❑Service Technician ❑Third-Party <br /> International Code Council Certification # : Expiration Date: <br /> ALTERNATE 2 (Optional) <br /> Designated Operator' s Name: Relation to UST Facility (Check Otte) <br /> Business Nante (Ifdierent from above): ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone # : ❑Service Technician ❑ Third-Party <br /> International Code Council Certification# : Expiration Date: <br /> 1 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, 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) . ��CJ )< e rot <br /> „ <br /> SIGNATURE OF TANK OWNER: <br /> DATE , OWNER'S PHONE # : yl OI- <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. waturb(iards . ca . Lov/ust/contacts/cupa agys . 111ml . <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> November 2004 <br /> i <br /> i <br />