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05/09/2008 08:50 FAX -r SJEH 0 003 <br />1* <br />owner Statements of Designated Underground Storage Tank (UST) Operator <br />and Understanding of and Compliance with US"T' Requirements <br />Faicility Name: n <br />paeisty AddresA: Rcasan for Suitnutting Ibis Form (Check One) <br />a,a, g 5,331 Change of Designated Operator <br />Facility Phone �: �_ .. . _ _. <br />operalm's Natpe: <br />Buaincsa Name (Ijd�&►ent <br />Deg�i,,, ated UST ODw tra or(s) Lar this F#cility <br />David A. Winkler <br />Afford* -Test <br />Dmiowded Opmw6 r'a Pbone A: 209 744-8112 <br />Inte" ionw Code Council Ccrtifcadon #; 5263373 -UC <br />Relation to UST Facility (Check One) <br />Service Technician <br />Expiration Datc: 3/3/08 <br />AI,T)eltxATE I(Upe►9_.. <br />Dn.-4ted Opexmws Name: - Zane A. Nhumo Itclatiun to UST Facility (Check One) <br />Huainess Nuns (I &ffa ant fr,o,a above)', Affords -Teat <br />Designated operaeor'9Phone 4: <br />204 74"112 Service Technician <br />International Code Council Cerdficedion k: 5263322 -UC - Expiration Da w: 2/3/09 <br />ALTERNATE 2 (00"Wo <br />rDDeai,d, 0pa.moe! Name: 1,ylc D. Nimmo [tolRtion to UST Facility (Chank vne) <br />Buelacm Naane (1fd&'-n! frau above): <br />D"ipnatod <br />I phone 0 - <br />_ AfYorda-Test <br />209 744.0112 <br />Intonational Coda Cowed CertiflCatlou k: 5249113 -UC <br />Service Technician <br />Expiration lute: 7/1/09 <br />L certify that, for the facility indicated at the top of this page, the individual(s) listed above Will <br />serve as Designated UST (perator(s). The individual(s) will conduct and document nnonthly <br />facility impactions and annual facility employee training, in accordance with Califon-" Cade of <br />Regulations, title 23, section 2715(c) - (f)- <br />Fdrtticrmore; I understand and am in compliance.vith the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Plaine Print): :, S A 13 <br />s1GmATI.mE OF TANK OWNER! <br />DATIE: OWNER'S P110ME # �� — -3 - --- <br />NOTE- l) SUBMIT Tins COMPLETED FORM TO THF LOCAL AGENCY (NOT THE STATE WATER <br />ItE30[1RC- S CONTROL. BOARD) BY JANU-%RY 1, 2005. THS LOCAL. AGENCY LIST IS AVAILABLE <br />AT: www,waterHgards.ca.gwlust/contaccslcu a s.htrnl. <br />2) NOTIFY THE LOCAL, AGENCY OF ANY CNANC-, FS TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANGE. <br />November 2004 <br />T R gCMH <br />� N3DU <br />THTHB 9t:60 B9eZlLt/t0 <br />