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APR-10-2013 09:47 From: 2098254549 To:4683433 Paee:16119 <br /> afoy"-Te 4162°d Street Phone:(209)744-0112 <br /> Galt,CA 95632 Fax:(209)744-0116 <br /> affords soflcom.aet <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Car Facility M <br /> Address: --0'j-- E�y� nsp j ¢V.,9 <br /> F lll�tom}'PltOfl .#- -x r7C�l e�L�—,I(sc� ❑Change of Designated Operator <br /> Kleen Cater WaSh �7d ❑ New Designated Operator <br /> L. Yosemite 336D <br /> Manteca, CA 95336ESIISNATED UST OPERATOR FOR THIS FACILITY- <br /> PRIMARY <br /> Desteeated Operator's Nam: ZANE N1MM0 Scniw'I'cehnieian <br /> Business Name: AFFORDA TEST ICC 4: 5263322-VC <br /> thsignated Operator's Phone: 209-744./1112 Expiration Date: 3/2/12 <br /> ALTERNATE I <br /> Desrenaled OucmtWs Name: FELIX RAMIRF,Z Service Technician <br /> Business Name AFFORDA TEST ICC a: 52733934-UC <br /> Designated Operator's Phone. 209-744-0112 Expiration Data 4/7/12 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINKLER ServiceTechnician <br /> .,. Busimvs Name: AFFORDA TEST ICC k: 5263373-UC: <br /> Designated Operator's Phone: 209-744-0112 Expiration pate: 3/24/12 <br /> ALTERNATE3 <br /> Ucaiimsfad Operator's Name LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC a: 5249115-UC: <br /> Designalud Operator's Phone. 209-744-0112 Expiration Date: 2/24/12 <br /> I certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Dn5ignated UST <br /> Operator. The individuals will conduct and document monthly facility inspections and annual facility employee training,in <br /> Accordance with California Code of Rcgulatiom,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): <br /> SIGNATURE OF TANK OWNER: wr, <br /> ND FTE: I sJ^ 2�� �_ OWNERS PHONE: QA- 02) < 33Z1) SUBM !THIS COMPLETED FORM TOTHE IACAL AGENCY(NOT SWRCB) R SJGN(NG.THE LQCAI..AGENCY <br /> LIST 15 AVAILABLE AT: w�watwboards.ca.g�p§,(/wntacL4cupa�lg s.ht 11. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: <br /> County: Date Faxed: Date Sunned: <br />