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Mar 30 11 05:30p AFFORDATEST 209-744-0116 p.1 <br /> ('t'lar,5u i I ICI ILp HrrVrCVH ICJI `" ' V• •v <br /> fforda-Te t 316 2nd Street Phone: (209) �4 t 0l I2' <br /> Cali,Ca 95632 Fax: (209) 44-0116 <br /> affords Ftcetn.net MAR R d gnu I <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with TJST Requirements s:NJI);•. <br /> Facility Name- )y_ t`.1 Facility sf. <br /> Address: $oZ�• O�etnn. � ��('\av� CZ <br /> Facility Phone H: Zoe? a�f�- X0$9 ❑ Change or ocsiguated Openlor <br /> New Designated Operator <br /> DESIGNATEID i ST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Dcsignatcd CW.mtor's Nome: ZANE NUM-MIO Scrvicc Technician <br /> ausimas Name: kFFORDA TEST ICC s: 5263322-UC <br /> D,zlenated Operator's Pnopc: 209-744-0112 Expiration Dote: 3!2/12 <br /> ALTERNATE 1 <br /> Dalgna¢d Operamr's Name: FEL1J\RA}I3 REZ Service Tedmieiao <br /> Ens incgs Nmne: AFFORDA TEST ICC 4: 52733434-(1C <br /> Design aled0p�xatoPs Piga:: '-09-'44-0112 Expim6on Datc: 47J12 <br /> ALTERNATE2 <br /> Ocsi,�nztcd Operators Nar,e: DAVID WINKLER Service Technician. <br /> euain,ss Name AFFOR0.4 TEST ICC 4: 52633T,,-UC <br /> DeSigi led Operator's Prate. 209-'443113 Expilalion Dale: 1=4/72 <br /> ALTERNATE <br /> Ocdgnaled O.wrator's Name: LYLE NFN[MO Sn:ee Technician <br /> Bwincss Name AFFORDA TEST ICC x: 5249115-1 <br /> Dalgnaicd Operatnr's PSone'. 109.744.0112 Expiration Dul 224!12 <br /> eenify'Itst-For the facility indicaled ut the top of this page, t6c irdividoals listed above wit;serve as Designmed UST <br /> Gpcmcors. The individuals will conduerand document monthly facility inspentions:a:d annual facility ernplopce training, in <br /> Accorcen«with California Code of Regulations,title 23,Section 27B(e)—Il <br /> Furthermore,I understand and am in compliance with the requireal(statutes,regulations,and local <br /> Ordinance l applicable to underground storage tames. <br /> NAME OF TANK OWNER(Print): <br /> SIGNATUR E O FTA N KOW.NCR: <br /> DATE: �}I`�O I !2/ OyvP7ETL4 PSOAS: g 2/ <br /> r.oTE: <br /> i) SLrDIt IT TH:S COMP!-ECED FORM TC THE LOCM..AGC!'(NOT S99Y CB)AFT£[t SIGK(NG.THE LOCAL AGENCY <br /> LIS-r IS AYAIL.ABLE.NT: v t tc beard. - ' Neo t eds/euan acrs.html. <br /> 2) I,1071FY TINE LOCAL-AGENCY OF ANY CHANGES TOTHIS INFOBMAIFCH WITHIN 30 DAYS OF THE CHANGE <br /> OFFICE: " 1 <br /> a30 <br /> Cou„ty1h„� Date Fazed: Dale Sunned: <br /> L-d Z6L;6£Z60Z 1-Ien POOH IIa4S d99Z0 L'. 0£ Je1N <br />