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Aug 19 09 11 : 37a Afforda-Test (204) 794-0112 P. 1 <br /> FROM MARIGOLDSHELL �tW',NO-' .`: 209 952 4962 ; Aug. 11 2009 02: 11PM P1 <br /> auv» V,3,.11 14.30 rrin rn ` ` '! uy V VL. <br /> ,AUG 19 2009 <br /> Afforda--Te t 416 2nd Street Ga14CzD1'9Fa 9X,0UN T' 209 744-0113 209 744.0116 FAX <br /> Owner Statemeats of Desi0 tT ftr0unld Storage Tank Operator <br /> and Understanding of and Compliance with UST Requiremtst6 <br /> aril tYama: � s iP'aeility#: <br /> AddreCc; on forth is form: <br /> Change of Designatod operator <br /> Facdfty p!tope#: 1,0� p� O Update Certificate Expiration Date <br /> DESIGNATED US�r OPERATOR FOItTFus FACIuTY; <br /> P>�1VIARY <br /> Deaignutcd Operator's Name: LYLE D.NUK&f0 Service Technician <br /> Susiues3 Name: AFFORDA.-MT 1CC 4 5249115 <br /> D" iced Operator's Phone#: 209 744-0112 Expiration Date: tttf3'AA4 C <br /> i <br /> ALTERNATE 1 <br /> Designated Oprrator'sNatne: DAVED A.` INKLER Sertice Technician <br /> nuatin msNam, AFFORDA-TENT ,TCC# 5263373• <br /> Dcsignated Operator's phone : 209 744-01 t2 -Ew.mianDale, 31;7/2010 <br /> ALTIJ>MATE 2 <br /> 79neted Operator's Name: ZANE A.7VllrMO Service Techniciun <br /> ausine"Name: AFFORDA-TEV lCG lk 5263322- <br /> DmiVmted Oposator's Phone*! 209744-0112 Expiration Date: 3/14/2010 <br /> ALTERNATE 3 <br /> Dmignated Ope ttor's Name: FEIr M Q RA111RE-Z Service Technician <br /> Business Name: AF ORDA=1'F1T LCC 5273934- <br /> Designated Operator's Phone#: 209 744-0112 Ex itatiotl Date: 6/21/2010 <br /> I oer ify that,far the fac[ y indUcated at the top of this page,the i nd iv iduals listed above wi!I szrvt:as lfsignated UST <br /> Operators. The individvala will conduct and document monthly facility inspections and annual facillty employee trainins'is <br /> accordance with Califtmis Coda of Regulations,tMe 23,section 2715 (c)-(f). <br /> i <br /> Furthermore, I •uderstand and am in cotnphaince witla the reyuirewcats (statutes, regulatious, and local <br /> ordinances) applicable to underground storm sanies. <br /> NAME OF'YANK OWNER (Print): <br /> SIGNATURE OF TANK ONVIS rR:C <br /> DATE: T�I�D OWNER'S PROrgE; [.s� 1��p <br /> 115`2 —49�7-1 <br /> 1)suave!'-mis COMPLEI o FORM Tori w LAc,A LAGENCY(N(n-STATE WATMRE90LMCE3 CONTROL AOARD)APMR <br /> �. SIONiNQ THE L.00ALA43ENCY LIST ISAVATLAeLE AT: www,wamboarda.ca.gov/ust/contaets/cupe 34tml- <br /> )rAOTIFY THE LOCALAGENCY OF ANY CHANCiES'I O TH7S tNFORMATiON WITHIN 30 BAYS OF T1dE CliANOL- j <br />