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NW-13-2013 15:06 From: 20913254549 To:4683433 Pase:4�19 <br /> CA <br /> ffo rd a-Te t 416 2""Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 <br /> affords softcom-Bet • 013 <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understandin of and Compliance with UST Re uirements TAL <br /> Facility Name: iC Facility #:zot'6— PON HEALTH DEPART NT <br /> Address: "j07 YtiroP t'3r— -4"c I \ Updataa O—uan Statement <br /> Facility Phone#: Z-0-L `CSZ'zi � I :;1 - 0 Cheap of Designated Oparsmr <br /> S KK 4 — I Do .----S U 0 f "7-S ❑ New Designnted Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> rRIMARY <br /> Designated Operator's Name: LANE NIMMO Service Technician <br /> Rwiness Name: AFFORDA TEST ACC#: SU3322-UC <br /> Desigasted Operator's Phone: 209-744-0112 Expiration Dere: M4 <br /> ALTERNATE i <br /> Designe:cd Opreamr'a Name: FELIX RAMIREZ Servide Technician <br /> Business frame: AFFORDA TEST ICC o: 52733934-UC <br /> Oesigaated Operator's Phone 209-744-0112 Expiration Date: 312114 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC 4: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 312/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: (,YLE NIMMO Service Technician <br /> Busiocas Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3M14 <br /> ALTERNATE 4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Busintss Name: AFFORDA TEST ICC# 5250492-UC <br /> Desigoated Operator's Phooe: 209-744-0112 Expiration Date. 1229114 <br /> 1 certify[last,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 sod annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)—(f). <br /> Furthermore,I understand sod am in compliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER/Operator(Print):Val)di I Enterprises Inc <br /> SIGNATURE OF TANK OWNER/Operator- ^ <br /> DATE: 6 t') 'I OWNERS PHONE: <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST is AVAILABLE AT: Marr rrrhwrds r I/ Vtootatbhana gpvSAlMI. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS W PORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICE: <br /> County: Date Faxed: Date Scanned: <br /> Date E-Ma(led <br />