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03/30/2012 09:45 FAX IM0001/0001 <br /> fforda-Tet 416 2n°Street Phone:(209)7440112 <br /> Galt,Ca 95632 Fax: (209)744-0116 <br /> allorclaqvsoftcont.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> FacilityName: S Facility <br /> Address: ��t✓ G /art P� In:>�� <br /> Facility Phone#: 54Uc ,NV^ ctv ❑Change ofDesignated Operator <br /> ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: ZANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST - ICC#:.5263322-UC <br /> Designated Operator's Phone: 209-744-0112 ;` Expirationlate:+ <br /> .. . . Linens, <br /> ALTERNATE I ,,nn'' <br /> Designated Operator's Name: FELLXRAMIREZ MAR O 'Dn�Aa,eggTecludeias <br /> Busiam Name: AFFORDA TEST 6Ye J0AGgWfi,S173p934-UC <br /> Designated Operator's Phone: 209-744-0112 NEAL!y GE Ei:pitation Date: 32/14 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 32/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 32/14 <br /> I certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Designated UST <br /> Operators. The individuals will conduct and document monthly facility inspections and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)—(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. Q <br /> NAME OF TANK OWNER(Print): 14 <br /> nl UL4 r",M R al y�i ZVV <br /> SIGNATURE OF TANK OWNER: ✓ "� i <br /> DATE: pZ 73 IZ OWNERS PHONE: Z---i- a-7/' 0-578 <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: www.w2terboards.ca.govfustleontacts/cuon aays.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> SCG.r\ 3iz <br /> �to834`'33 <br />