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06/01/2012 09:34 FAX _ f�J0001/0001 <br /> r: <br /> fforda-Tet <br /> 416 2v4 Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 ✓(/� "j <br /> affords ftcom.net 0 <br /> Owner Statements of Designated Underground Storage Tank Operator ✓;, ��1,� <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: `L3 Facility <br /> Address: /bZZ Front shei ZO F\W� rs jz'jeOA CA <br /> Facility Phone#: SCS O Change or Designated 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 N: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3!2/14 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Data 3!1/14 <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: 3014 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLENIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3!1/14 <br /> 1 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 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. <br /> NAME OF TANK OWNER(Print): RSLtipat L �Hpc 1 t (a.l to L <br /> SIGNATURE OF TANK OWNER: <br /> DATE: S-ZZ I2_ OWNERS PHONE: Qtf- 592 a/�L <br /> NOTE: <br /> I) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: www.watabmds.mxov 0cantacWcuoa aays.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: C t <br /> County: JJC. Date Faxed: (a 2 Date Scanned: (p It 1� <br /> 443- 343'3 <br />