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10/21/2010 13:20 FAX 100001/0001 <br /> -yW-3433 To.--440116 Paee:1/1 <br /> OCT-21-2010 12:47 From: <br /> fforda-Te 4162"d Street phone; (209)744-0112 <br /> Galt,Ca 95632 Fax: (209) 744-0116 <br /> afforda@softeoni.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name i i l ck-A kj e etJ 60-r k )AGA )r acility#: <br /> Address: '7:4-0-4— e7- l-U-2 <br /> Facility Phone#: - 43�z--5_ctt sq [ICbattgeof Designated operator <br /> ❑ New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILTCY: <br /> PRIMARY <br /> Designated Operator's Name ZANE NIMMO Service Technician <br /> Business Name: AFFORDATEST ICC R: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3x2/12 <br /> ALTERNATE <br /> Designated Operators Name. FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC a: 52733934-uC <br /> Designated Operators Phone- 209-744-0t L2 Expiration Date: 47/12 <br /> ALTERNATE2 <br /> Designated Operator's Name DAVTD WINKLER Service Technician <br /> Business Name: AFFORDA TEST <br /> [CC At: 5263373-UC <br /> Designated Operator's Phone. 209-744.0112 E.tpiralion Date: 1124.,L2 <br /> ALTERNATE3 <br /> Designated Operator's Nam: LYLE NIMMO ' Service'feehniciat <br /> Business Name: AFFORDA TEST ICC 9: 52d9115-UC <br /> i <br /> Des,snatcd Operator's Phone. 209-744-0112 g¢pttmion Date 2/2dlt2 <br /> I certify that,for the facility indicated at the top of this page,toe individu215 listed above will serve as Designated VST <br /> Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training,in <br /> Accordance.vith California Code of Regulations,title 23,section 2715(c)-(f). <br /> Furthermore,I understand and am in mrapliance with the requirements(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Print): r4 1J P N ^. c G bQ t <br /> SIGNATURE OF TANK OWNER: ( �✓lIGl. r�Ow - `� - <br /> DATE: 1 b— Z Z - 10 OWNERS PHONE: 4p C <br /> NOTE: <br /> i) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)A•MR SIGNING.THE LOCAL AGENCY <br /> LIST 15 AVAILABLE AT: naltpt2gyS.4Sn:S- <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION wrrmv 3o GAYS oFTHE CHANGE. <br /> OFFICE: <br /> County: pate Faxed: / / Date Scaium d: 10 n <br /> r <br />