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DEQ`-06-2007 18:2:3 Service Station Systems 438 938 8888 P.02 <br /> Owner Statements oesiatiated Underground Storage Tank (UST) Operator <br /> andUnderstanding of and Compliance with UST Requirements <br /> atilitxhama; {� s �� Facility 11)#) r <br /> Facility Address: <br /> 4-D 19 !il 0 �n . Reason for Suhmilting this Foran(Check Ortel <br /> racility Plime 0; ,r � 'r,. ('/I � , Change of Designated Operator <br /> Designated UST Opelratorfs)fur this Facility <br /> PR NARY <br /> Designated Operator's Name: David A. Winkler halation to UST Facility(CAeck Cine) <br /> Busirscss Namc(If differerrt from above): Alrforda-Test <br /> Designated Dperait:r's Phone#: 209 744-0112 Service Technician <br /> Intonational Code Council Certi&cation#: 5263373AT ExgirLtioo Date; 3/3/013 <br /> AI.TLRNATE 1. D doral <br /> Designated Operator's Name: Zane A. Nirnino RolatiOn Lo UST Faciligy(Check Orae) <br /> 1JU";jincssNamc(lfd2fferewftontabove): Afforda-Test <br /> Designated Opetator's Phone V. _ 209 744-0112 Service Technician <br /> Tnternationa]CodcCouncii Certitieatiop#l. 5263322-UC rxpiratioax bate: 2/3/0$ <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name: Lyle D.Nitmno Relation to UST Facifity(Check Cine) <br /> 1191n=Name(1f dYforew from above): Afforda-Test I <br /> Designated Operators Photic#: _ 209 744-011.2 Service Technician <br /> International Cade Council Certification#: 5249115-UC Ivxpiration Dare: 7/1/09 <br /> 1 certify that,for the facility indicated at the top of this page,the individual(s) listed above will <br /> serve as Designated UST Operator(s)- The individuals)will condueL and document monthly <br /> facility inspections and annual facility employee training, in accordance with California Code of <br /> Regulations, title 23, section 2715(c) - (f). <br /> Furthermore,I understand and am in compliance with the requirements (statutes, <br /> regulations,and local ordiinances) applicable to underground storage tanks. <br /> 0. <br /> NAME OF TANK OWNER(Please Prini): r <br /> /1 C� <br /> SIGNATURE OF TANK OWNER: � -- <br /> DATE; OWNER'SFH �E#:flo u_) 37A b6 9 1 <br /> NOTE: 1)SUBMIT TIi1S COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,1-005.THE LOCAL AGENCY LIST IS AVAILABLE <br /> AT, www,watorthn�r[ls,c'.>c�vlu_�t/ccantncra/ctsa agys.html. <br /> 2)NOTIFY TaE LOCAL AGENCY OF ANY CHANGES TO THIS lh'ts'ORMATION WITHIN 30 DAYS <br /> OF THE CHANGE. <br /> Novcmbcr 2004 <br /> TOTAL P.©2 <br />