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No. 3933 P. 2 <br />■ Jul. 30. 2010.11:06AM 1209 _744-L..0 12 <br />■Jul r_.J .0 +-+ter nffo�a Test <br />■ <br />■ <br />■ <br />fforda-Tet 4162°°Street phone: (209)/44-0112 <br />Galt, Ca 95632 Far (209) 744-0116 <br />affords ofteotn.nel <br />Owner Statements of Designated Underground Storage Tank Operator 92010 <br />and Understanding of and Compliance with UST Requirements <br />Address: 2432 E <br />Facility Phone #: <br />0 Change ofD�Ignatcd Operator <br />❑ New I)=%Ratcd OperMtor <br />DESIGNATED <br />UST OPERATOg FOR <br />TRTS FACILITY: <br />PRIMARY <br />ZANE NIMMO <br />Service Technlclan <br />Do,ignared Operator's Nom-; <br />AFFORDA TEST <br />1CCa 5263373,UC <br />Dcsignettd Optrutor's Phonc: <br />AFFORDA TEST <br />ICC N: 5263322 -UC <br />Business Name, <br />Designated Operator's Phone: <br />209.744-0112 <br />Expiration Date: 3/2112 <br />ALTERNATEI <br />AFFORDA TEST <br />ICC it: 5249115 -UC <br />D"isMatcdOperator's Name: <br />FELIXRAMIREL <br />ScryceTechntolsa <br />Business Name <br />AFFORDA TEST <br />ICC N: 52733934 -UC <br />Cxplrstlon Date: 4/7/11 <br />Deslpaaicd Opcmxor•s Phone: <br />209.7444DI 12 <br />ALTERNATE2 <br />DAVID WINKLER <br />Service Technieian <br />DraignaLod Operators Name; <br />BwinessNamu: <br />AFFORDA TEST <br />1CCa 5263373,UC <br />Dcsignettd Optrutor's Phonc: <br />2D9-744.0112 <br />£<piration Dow ^$/74/12 <br />ALTERNATE3 <br />Designued Operator's Name: <br />LYLE NIMMO <br />Srnlce Technician <br />Busiaes Namc: <br />AFFORDA TEST <br />ICC it: 5249115 -UC <br />Designmcd Operator's Phone- <br />209.744.0112 <br />Expirinlon Dam: 2/14/12 <br />I certify that, for the facility indio;nod at d1c top of ih(s page, the individuals listed above Will Scrve as Desigoamd UST <br />Opetawrs. The indlvlduais Will conduct and document monthly Pnellity inspections and annual facility employee tralning, In <br />Accordance with California CDdc of Rcgulatlons, title 73. 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 terms. <br />NAME OF TANK OWNER (Print): <br />SIGNATURE OF TANK OWNER: <br />DATE: 1�2%m—ld OWNERS PHONE,. C�7 J 9TH �3C� r <br />NOTE <br />1) SUBMt7 THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB)ApTD-R SIGNMO. THE LOCAL AGENCY <br />LIST IS AVAILA9L£AT' s rlry ds en / J i ty n ages ht 1. <br />2) NOTIFY T'FIE I,OCAI. AQENCY OF ANY CHANGES TO THIS INFORMATION WFIHIN 30 DAYS OFTHE CHANGE, <br />OFFICE: <br />County: Date Faxed: Date Scanned: <br />Z00 [i� H3fS - 1Vd LS:CT 60/60 OTOZ <br />