Laserfiche WebLink
RECEIVED 07/02," 3 11: 05 RECEIVED <br />013 <br />i i <br />f o rda--Tei,, t 1416 2a° Street Phone: (209) 744-0112 <br />iGalt, Ca 95632 Fax: (209) 744-0116 ENVIRONN U <br />nffordaCa scifteom.net HMLTH DEPA ITM <br />Owner Statements of Designated Underground Storage Tank Operator <br />and Understia:ndioa of and C.'onlnliance with UST Requirements <br />� Facility Name: Fast N F sy Facility t#: 16 PO# <br />Address: 1399 E. Yosemite Manteca,CtL 95336 7 T;dated Owners Statement <br />Facility Phone #: '20 j „. 9 -2 S - 3 f16 b M Change of Designated Optrator <br />Cl NCW Dcsiguatcd Operatur <br />DFSIGNATET) UST OPERATOR <br />FOR THIS FACILITY: <br />PRIMARY <br />Utsignattd Operator's Name: <br />ZANE NINIMO <br />Service Technician <br />Business Name, <br />AFFORDA TEST <br />ICC #: 52633:2-11C <br />Ilrsignated Optrator's Phone: <br />:09.744-0112 <br />Expiration hate: 3/2114 <br />ALTERNATE <br />Deaigaattd Operator's .Nanta: <br />FELIX R ,%UR,EZ <br />Scrvice Ttchnivian <br />Business Name. <br />,AFFORDA TEST <br />ICC #: 32733934 -UC <br />Designated Operator's Phone: <br />209-744-0112 <br />Expiration Date: 3/1,14 <br />ALTERNATE 2 <br />Designated Operator'sNaare: <br />DAVID WINKLER <br />ServireTrchnician <br />Business Name: <br />AFFORDA TEST <br />[CC p: 5263.171 -UC <br />Dcsiguatcd Operator's Phont: <br />2.09-7444112 <br />Expiration Date: 31/14 <br />ALTERNATE. 3 <br />Uesigaattd Uperator's !ratue: <br />LYLE NIMMO <br />Service Technician <br />BusintssNanic: <br />AFFORDA TEST <br />ICC++: 5249115 -UC <br />Dcsignated Operator's Phone: <br />209-744.0112 <br />Expiration Date: 3T2114 <br />ALTERNATE 4 <br />Designated Operator's Name: <br />EDWARD S"TEARNS <br />Service Technician <br />Business Name: <br />AFFORDA TEST <br />ICC: x 5250492 -UC <br />Deaigttated Operator's Phone; <br />20'3-744-0112 <br />Expiration Date: 12129/14 <br />I certify that, for the facility indicated at the top of this page, the individuals listed above will verve as Designated UST <br />Operators. The individuals will conduct and document monthly facility inspections and annual facility employee <br />training;, in <br />Accordance with California Code of Regulations, title 23, section 2713 (c) -O. <br />Furthermore, I understand and ash in compliance with the requirements (statutes, regulations, and local <br />Ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Print): �._ _ _ V i k PZA M V O H IZ A t� V PJ AA vol P' A <br />SIGNATURE OF TANK OWNER: <br />DATE: <br />NOM <br />-7--2--2013 <br />ONVNERSPHONE: S�5q--2t y - oil 6q <br />1) SUBMIT THIS COMPLETED FORM TO THF LOCAL AGENCY (NOT swRCB) AFTER SIGNING. THE LOCAL <br />AGENCY LIST 1S AVAILAB1.1yAT. www'vv bu s. 9• ov' /on ref%gYl.htrtlJ. <br />2) NOTIFY THE LOCAL AGENCY OF A.'V Y CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />OFFICE. <br />County: Date Faxed: '7-2--2c',/3,-- Date Scanned: 1-2-2013 <br />Date E -Mailed 7-2-203 <br />