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Jan 13 11 09:44a AFFORDA TEST 2/'^-744-0116 p.1 <br /> is i i <br /> fforda-Tet <br /> 416 2"d Street Phone:(209)744-0112 <br /> GMM Ca 95632 Fax: (209)744-0116 JAN 13 2011 <br /> Aof fa rd a(a�en ft a om.ne t <br /> Owner Statements of Designated Underground Storage Tank Operator �� <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: ABC Food Mart Facility#: <br /> Address: 713 N El Dorado St Stockton CA <br /> Facility Phone#:209-465-5222 ❑Change of Designated operator <br /> N New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: ZANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52 ^ C <br /> Designated Operator's Phone: 209-744- xpir . 3,12/12 <br /> ALTERNATE 1 <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ]CC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 4/7i 12 <br /> ALTERNATE 2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC 9: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/24112 <br /> ALTERNATE 3 <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744.0112 Expiration Date: 2/24112 <br /> I certify that, for the facility indicated at the top of this pagthe individuals listed above will serve as Designated UST <br /> Operators. The individuals will conduct and document mi-thly facility inspections and annual facility employee 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(statutes,regulations,and local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Print): 5; <br /> SIGNATURE OF TANK OWNER: <br /> DATE: � ;��a r"fs�% OWNERS PHONE: a�! 7co a <br /> NOTE: <br /> 1) SUBMITTHIS COMPLETED FORM TOTHE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: tivNvw.waterboards.cagov/ust/contacts.'cupa ages-html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE.- <br /> county: <br /> FFICE:County: 5AN) JO� A-Q,41,� Date Faxed: /o2'/6 %L)Date Scanned: <br /> f J <br />