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RECEIVED 80121/2013 15:44 I <br /> RIJG-22-2013 15:33 From: 2998254549 To:2097440116 f3ftNE'�Ep <br /> 21 4013 <br /> FEEA <br /> fforda—Te t 416 2n4 Street Phone:(209)744-0112 E <br /> Gait,Ca 95632 Fax!(209)744-0116 HN <br /> affords softcom.net HEALTH EP ML <br /> ENA <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Com (lance with UST Requiranxilidth <br /> Facility Name: (dcl 4/1 Facility#; POM <br /> Addreast `)O7 y04-*-W%C}1-4 do/%4— Updatod Owners Statement <br /> Iraell(Iy Toone N: ❑change ofl)esigaated Operator <br /> ❑ New Desigoated Operator <br /> DE3AGNATTA UST OPERATOR FOR TRIS FACIISTYe <br /> FFIUOAKY <br /> DeslgnNed tlperaror's Name: ZANENIMMO Service Technician <br /> Ru,;a•.=<Name: AFFORDA TEST ICCa: 5263922-UC <br /> Decianated Operator's Phano: 209.744,0112 £xpiratioa pato: 3WI4 <br /> ALTERNATE <br /> DwKt .Ren Operam -.Name: )FJLs XX%An1XRxz 94rrtea Taahgotan <br /> Ensluse Name: AFY"RUA TEST TCCA: 92733934-UC <br /> Designated Operator's Phone: 2p9-7440112 Expiration Date- 312/14 <br /> ALTERNATE <br /> Dtaigttalte Operamr`s Name; DAVIDWLYKLER Sc"ise Technician <br /> Bu5iaR 55 Nam¢: AF i�FORDA TEST ICC q:5MM73dJC <br /> pesigaat¢d Operator's Fbsae: 299.744-0112 Expiration Date: 312/14 <br /> ALTERNATE <br /> lirsignated Operamrs Namt: LYLE NL)4IM0 Service Techuiciaa <br /> 6ustow Name: AFFORDA TEST ICC#: 5249115.UC <br /> Desigoamd operator's rhoaet 299.744.9112 Sxplrenon Date: 9.^X/1A <br /> ALTERNATE 4 <br /> Designated operator's Names EDWARD STEARNS Service Technician <br /> [tasiness Name: AFFORDA TEST ICC#SISU92-VC <br /> Desiyramd Operator's Phone: 209-744-0112 Lxpirstion Dant 12/29/14 <br /> I certify that,far the facility indicated at the top of this page,the individuals listed above will serve as Aesigoated UST <br /> Operators. The individuals will conduct and document monthly ihcitlty inspections and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 239 section 1715(c)—(O. <br /> Fwtharmora,I understand and am in compliance with the roquirtmentt(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER/Operator(Print):Vats d I Entelp11S/Cs Inc <br /> SIGNATURE OF TANK OWNER/Operator <br /> ir— <br /> DATE: OWNERS PRONE: <br /> NOTE! <br /> 1)WBMnrX TW8 COMPLETED FORM TO THL LOCAL AGENCY(NOT SWRCR)AFTER SIGNING.THE LOCAL <br /> AGENCY LAST 15 AVAn.ADLEAT-. terbnsrds,eesa (sap is !C`pp } h[ml. <br /> 2) NOTIFY THE LOCAL AGENCY Of ANY CHANGES TO THIS I47ORM.ATION WITHIN 30 0A"OF THE <br /> CHANGE. <br /> OFFICE: n <br /> County! V Date Faxed: Date Scanned: VP-143 <br /> Date E-Ma iced <br /> 33 <br /> Nt;� oE32 <br />