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Tra NTS TLI�uY 8 fforda- 1e t 4162""Street Phone: (209) 744-0112 Galt,Ca 95632 Fax: (209) afforda@softcom.net Owner Statements of Designated Underground Storage Tank Opera r �= and Understanding of and Compliance with UST Requirements OCT 05 201-, `r Facility Name: " Faci Address: -q-b'7- , j�0saftu� A-04 E14VIFONMEiNTAL F flit Phrx 1t�e1�t g2-3_Rt5cr ❑ �ii l changeo6T;t b'Lh4 N Kleen Car Wash ❑ New Designated Operator E. Yosemite Ave Manteca, CA 95336 336bESI(INATED UST OPERATOR FOR THIS FACILITY: PRIMARY Designated Operator's Name: ZANE NIMMO Service Technician Business Name: AFFORDA TEST ICC#: 5263322-UC Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/12 ALTERNATEI Designated Operator's Name: FELIX RAMIREZ Service Technician Business Name: AFFORDA TEST ICC#: 52733934-UC Designated Operator's Phone: 209-744-0112 Expiration Date: 4/7/12 - ALTERNATE2 Designated Operator's Name: DAVID WINKLER Service Technician Business Name: AFFORDA TEST ICC#: 5263373-UC Designated Operator's Phone: 209-744-0112 Expiration Date: 3/24/12 ALTERNATE3 Designated Operator's Name: LYLE NIMMO Service Technician Business Name: AFFORDA TEST ICC#: 5249115-UC Designated Operator's Phone: 209-744-0112 Expiration Date: 2/24/12 1 certify that,for the facility indicated at the top of this page,the individuals listed above will serve as Designated UST Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training,in Accordance with California Code of Regulations,title 23,section 2715(c)—(f). Furthermore,I understand and am in compliance with the requirements(statutes,regulations,and local Ordinances) applicable to underground storage tanks. NAME OF TANK OWNER(Print): F I a,N P B hj e IgG c bGi h SIGNATURE OF TANK OWNER: 5 �4LA DATE: O ZZ ' D OWNERS PHONE: 8 NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AMR SIGNING.THE LOCAL AGENCY LIST IS AVAILABLE AT: ate bo rds ca e / st/co tacts/cupa ae s html. 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. OFFICE: County: Date Faxed: Date Scanned: