Laserfiche WebLink
*ffor4d!a-Te <br /> t 416 2"d 5tree# Ph ne: (209)744-I Gait,Ca 95632 Fax:(209)744-01.16 WED affords a�softcom.net <br /> Owner Statements of Designated Underground Sto age'l ank Operator <br /> and Understanding of and Compliance with UST Requirements JUN b + 2016 <br /> HEALTH <br /> Facility dame: Food Mart&Gas Facility ID# 1450ENVIROPtfAEATAL <br /> 1 PO# ENTALERVIirES <br /> Address: 2185 E Fremont Street Stockton CA 95206 ® Updated Owners Statement <br /> ❑ Change of Designated Operator <br /> Facility Phone 4: 209-547-1.700 ❑ New Designated Operator <br /> DESIGNTEP UST OPERATOR FOR THIS VACTLITY: <br /> PRIMARY Service Technician <br /> Designated Operator's Name: FELIX RAMIREZ ICC#: 52733934-UC <br /> Business Name: AFFORDA TEST <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 2-26-I8 <br /> ALTERNATE 1 Service Technician <br /> Designated Operator's Name: DAVID WINKLER ICC 4: 5263373-UC <br /> Business Name: AFFORDA TEST Expiration Date: 2-26-1.8 <br /> Designated Operator's Phone: 209-744-0112 <br /> ALTERNATE 2 Service Technician <br /> Designated Operator's Name: EDWARD STEAI2NS ICC#: 5250492-UC <br /> Business Name: AFFORDA TEST <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 2-26-18 <br /> I 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 inspections and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)--(f). <br /> Furthermore,I understand and am in compliance with the requirements(statut ,regulations,and local <br /> ordinances)applicable to underground storage tanks. <br /> NAME OF TANK OWNEWOperator(Print): - �" 1—' <br /> SIGNATURE OF TANK OWNER/Operator: <br /> _ 7 c� <br /> DATE: 7 /� OWNERS PHONE::i — <br /> NOTA: <br /> 1) CUSTOMER IS RESPONSIBLE TO UPLOAD TIIIS FOR K TO CIrRS PER YOUR LOCA <br /> REG[iLATIONS.AFFORDA TEST DOES NOT UPLOAD TC I CERS. <br /> 2) NOTIFY THE FOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 <br /> DAYS OF THE CHANGE. <br /> OFFiCE. Date Scanned: Date E-Mailed <br /> County: San Josquln Date Fazed: _ <br />