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12/10/2010 14:45 FAX 160001/0001 <br /> fforda-Te t 416 2nd Street Phone:(209)744- -i3 ^ <br /> Galt,Ca 95632 Fax: (209)74401 6 -1 <br /> afforda oftcom.net A,y <br /> Owner Statements of Designated Underground Storage Tank Operator - <br /> DEC 1 <br /> and Understanding of and Compliance with UST Requirements 2010 <br /> Facility Name: ABC Food Mart Facility <br /> Address: 713 N EI Dorado St Stockton CA <br /> Facility Phone#:209-465-5222 ❑ Change of Designated Operator <br /> ® 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#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/7/12 <br /> ALTERNATE 1 <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 4/7/12 <br /> ALTERNATE 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: 3/24/12 <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: 2/24/12 <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 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): `��� L2� % S A417' <br /> SIGNATURE OF TANK OWNER: <br /> DATE: �a OWNERS PHONE: �G/ 76o <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: www.watcrboards.ca.zov/ust/contacts/cuE)a agys htmi. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: <br /> County: 5A0 jo A-Q u.14 (o Date Faxed: Date Scanned: 4-110— //�, <br /> 644�- 3 0$ —?Li,33 <br />