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Aft"1416 2"° Street <br />Galt, Ca 95632 <br />affordaAsoftc4 <br />Phone: (209) 744-011 <br />Fax: (209) 744-0116 <br />Owner Statements of Designated Underground Storage Tank Operator <br />and Understanding of and Compliance with UST Requireme,� <br />Name: Food Mart &c Gas <br />Facility #: PO# <br />014 <br />H�ALTF <br />Address: 2185 E Fremont Street Stockton CA u Updated owners Statem¢nY <br />Facility Phone #:209-547-1700 ❑ Change of Designated Operator <br />® New Designated Operator <br />ES GNATED USI OPERATOR FOR TMS FACILITY: <br />PRIMARY <br />Designated Operator'sNamm ZANE NIMMO Service Technician <br />Business Name: AFFORDA TEST ICC M. 5263322 -UC <br />Designated Operator's Phono, 209-744-0112 Expiration Date: 3/3/16 <br />I <br />ALTERNATE 1 <br />Designated Operator's Name: FELIX RAMIREZ Service Techniciao <br />Business Name: AFFORDA TEST ICC #: 52733934 -TIC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/1.6 <br />,A.LTERNATE 2 <br />Designated Operator's Name: DAVID WINKLER Service Technician <br />Business Name: AFFORDA TEST ICC #: 5263373, -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/10/16 <br />ALTERNATE 3 <br />Designated Operator's Name: EDWARD STEARNS Service Technician <br />Business Name: AFFORDA TEST ICC #: 5250492 -UC <br />Designated Operator's Phone: 209744-0112 Expiration Date: 313/16 <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 />Aeennionre with California Code of Regulations, title 23, section 2715 (c) — (t). <br />Nurdmmurm I uudervuM and um is cmqftipeo with the raqulrime.Wx (Nti Ulm maw*" and 461 <br />Ordhonem) :qppH=ble to oader%muud storage tasks .^� n <br />NAME OF TANK OWNER (Print): <br />SIGNATtME OF TANK OWNER: m <br />DATE: ,., r„ OWNMS Pi on; <br />NOTis: <br />1) SU$11ri'1' 'O1L1 LV4?1-VrM FORM TO TM LOCAL AtighlCY (NOT SWRCn) AFTEk SIONANC, THX LOCA. <br />ACFSICY LIST 15 AVAILABLE AT: <br />l) NOTIFY THE LOCAL ACENCY OF ANY CBAN ES To THIS INFORMATION WITHIN 30 DAYS OF 110 <br />CHANOX. <br />OFFICE: <br />Cauntr:j J C_ Nic Faxa1: ' '� ^ �' Date Scanned: —7~ <br />13414 k,-Wled " <br />