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416 2a'Street Phone:(209)744.0112 <br /> �' `o r�_7�i <br /> __._ Galt,Ca 95632 Fax:(209)744-0116 015 <br /> - — affords oftcom.net 'UL 0 6 <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements j. vIRONMENTAM <br /> Facility Name: A i-PNA /SAS- i�AS Facility ID# PO# <br /> Address: 1551' WA-re e-LoD '2P, 415ZOS ® Updated Owners Statement <br /> Change of Designated Operator <br /> Facility Phone ❑ New Designated Operator <br /> DES NATFD 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 Expiration Date: 3/3/16 <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 Date: 313/16 <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: 3110/16 <br /> ALTERNATE3 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC M. 5250492-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/16 <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 <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2115(c)–(I). <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/Operator(Print): <br /> SIGNATURE OF TANK OWNER/Operator. _ <br /> DATE: i//J QWNERSPHQNE: 12 '/ <br /> NOTE: <br /> 3) St7BMil'THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SW RCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: g'ng,,watcrboard.res aovlwt/centacts/cuaa inn htmi. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OF"C CE. <br /> County: 8y— Date Faxed: Date Scanned:vj4z <br /> Date E-Malted 7�),� <br />