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OCT-25-2010 22:15 From: <br /> To:aF83433 Paae:9112 <br /> Tra N <br /> fforda-Te 4162nd Street Phone- (209)744-0112 <br /> Gait,Ca 95632 Fax: (209) 744-0116 <br /> affords ci)softcom-net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility #: <br /> Address: -zit-D-7- 15�, DSelrUAM A-UA-Q <br /> F "its' Ph W- .� $�3�Gt( �►G� ❑Change of Designated Operator <br /> Kieen Car Wash ❑ New Designated Operator <br /> L. Yosemite Ave�ESIC±<NATED UST OPERATOR F R THIS FACILTTX: <br /> Manteca, CA 95336 <br /> PRIMARY <br /> Designated Operators Name. ZANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST 1(.C#: 5263322-VC <br /> Designated Operator's Phone: 209-744-0112 (expiration Date: 3/2/12 <br /> ALTERNATEI <br /> Designated Operator's Name FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Desienated Operators Phone 209-744-0112 Expiration Date: 4/712 <br /> ALTERNATE2 <br /> Designated Operator's Name. DAVID WINKLER Service Techoician <br /> Business Name: AFFORDA TEST ICC#: $263373-UC <br /> Designated Operators Phone: 209-744-0112 Expiration Date: 3124/12 <br /> ALTERNATE3 <br /> Designated Operator's Name. LYLE NIMMO Scrvice Techoicion <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> ths.gnated Operaror's Phone 209-744-0112 kxpirat,oa Dale: 2/24112 <br /> 1 certify that,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 inspcetions and annual facility employee training,in <br /> Accordance with California Code of Regulations,title 21 section 2715(c)—(Q. <br /> Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Print)- I-&tJC"eN _ aC-obak- <br /> SIGNATURE OF TANK.OWNER: <br /> DATE: D_ OWNERS PHONE: D�� <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM-TO"TH5 LOCAL AGENCY(NO'TSwRC:I3)AI� RSIGNING.TI IE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: www watemoards ca aov/u5L'c1lPtlrl'kislftiLBlk3' html. <br /> 2) NOTIFY-THE LOCAL AGENCY OF ANY CHANC.r_S TO1-1IIS INFORMATION WITHI N'10 DAYS 0FTHE CHANGE. <br /> OFFICE: <br /> County- Date Faxed: Date Scanned: <br />