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;o rd lT 416 2.d Street Phone: (209) 744-0112 <br />1 i� Galt, Ca 95632 Fax: (209) 744-0116 <br />Owner Statements of Designated undergrouno atorugic <br />_ and Understanding of and Compliance with UST Re <br />Name: Miracle Mite Facility #: <br />DEC 0 9 2014 <br />Address: 244 W Harding Stockton CA U Updated Owners Statement <br />Facility Phone #: ❑ Change or Designated Oprrnarr <br />Z New Designated Operator <br />DESIGNATED UST OPERATOR FOR THIS FACILITY: <br />PRIMARY <br />Designated Operator's Name: ZANE NIMMO <br />Business Name: AFFORDA TEST <br />Designated Operator's Phone: 209-744-0112 <br />ALTERNATFI <br />Designated Operator's Name: FELIX RAMIREZ <br />Business Name: AFFORDA TEST <br />Designated Operator's Phone: 209-744-0112 <br />ALTERNATE2 <br />Designated Operator's Name: DAVID WINKLER <br />Business Name: AFFORDA TEST <br />Designated Operator's Phone: 209-744-0112 <br />ALTFRNATF.3 <br />Designated Operator's Name: EDWARD STEARNS <br />Business Name: AFFORDA TEST <br />Designated Operator's Phone: 209-744-0112 <br />Service Technician <br />ICC #: 5263322-1'C <br />Expiration Date: 3/3/16 <br />Service Technician <br />ICC #: 82733934-tJC <br />Expiration Date: 3/3/16 <br />Service Technician <br />ICC #: 5263373 -UC <br />Expiration Date: 3/10/16 <br />Service Technician <br />ICC #: 5250492-13C <br />Expiration Date: 3/3/16 <br />certify that, for the facility indicated at the top or 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 ('ode of Regulations, title 23, section 2715 (e)—(). <br />Furthermore, I understand and am in compliance with the requirements (statutes, regalaHons, and local <br />Ordinances) applicable to underground storage Maks. <br />NAME OF TANK OWNER/Operator (Print): <br />SIGNATURE OF TANK /OWNFRIOperator. <br />DATE. �? f G / 20/ Y OWNERS PHONE: 9 Y1 ' 69b '7 <br />❑C <br />AL HEALTH <br />NOTE: <br />q SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB) AFTER SIGNING, THE LOCAL <br />AGENCY LIST IS AVAILABLE AT: W" aater1sw rds&A ®arlast&'aegirraa anj9ttal. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES I0 IIIIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />OFF/CE: <br />County: Date Faxed: ___._.„.,"-_-� Date Scanned: ,.� Date E -Mailed <br />