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RECEIVE® <br /> ffortla-Te t 410 Ino Street Phone:(209) APR 07 2014 <br /> Galt,Ca 95632 Fax:(209)744-0116 <br /> - affords ofteom.netAL HEALTH <br /> Owner Statements of Designated Underground Storage Tank Opera or DEPARTMENT <br /> and Uaderstandin nc <br /> of and Com Bae with UST Requirements <br /> Facliity Name: Woodbridge Arco AM PM Facility#: 1552-1 POO <br /> Address: 18806 Lower Sacramento Road Woodbridge CA.95258 ®Updated Ownvs Statement <br /> Facility FhoRe#:209-339$238 Q Change of O.iguated Operator y <br /> ❑ Nett Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS VACILI'1'Y: <br /> PRIMARY <br /> Desipsated Operator's Name: Z.ANE NIMMO service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3WI6 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST TCC#t 52733934-13C <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 313116 _ <br /> ALTERNATF 2 <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: 3110,116 <br /> ALTERNATF3 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5250492-UC <br /> Designated Operator's Phone: 209-744-0)12 Expiration Date: 3/3!16 <br /> 1 certify that,for the Facility indicated at the top of this page,the iadkiduals listed above will serve as Designated UST <br /> Operators. The individuals will conduct and doeament monthly facility inspections and annual facility employee <br /> tralning,in <br /> Aceordante with California Code of Regulations,title 23,sectlou 7,715(c)-(1). <br /> Furthermore,I understand and am in comp0ance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to uudergrouod ooraQetanks. <br /> NAME OF TANK OWNER(Print): 3 o 4-4 <br /> SIGNATURE OF TANK OWNER: ,�-- <br /> DATE: ,3 - as - 1 OWNERS PHONE; & r <br /> ( NOTE: <br /> i) BDBhBTTH16 COTwL6TEA FORM 70 TBE LOCAL AGENCY('t0'['StYtiCn)AIr['F'¢ $IGNTVG.TtIE LOCAL <br /> AGENCY LIST IS AVAIlAMZ AT: mrss�ht I. <br /> -) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATIQN W rFHIN 3e DAYS OF THE <br /> CIBANGE. <br /> OFFICE., <br /> Co¢¢ty: Date Faxed: 4-1-ii Date Seanned: <br /> Date E-Mailed <br /> � d <br /> e4:0S pI0Z19Z/£8 (13AIBD32i <br />