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Jan 09 09 11 : 44a nffarda-Test (209) 794-0112 p. l <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> ' l <br /> FacilityName: �' /7_ <br /> 17 Facility#: <br /> Address: Reason for this form: <br /> /-� n/ r L ���►'/�1'D S J _ _� � �y ❑ Change of Designated Operator <br /> Facility Phone#: l <br /> 0 Update Certificate Expiration Date <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: LYLE D.NIMMO Service Technician <br /> Business Name: AFFORDA-TEST ICC# 5249115 <br /> Designated Operator's Phone#: 209 744-0112 Expiration Date: 7/1/2009 <br /> ALTERNATE 1 <br /> Designated Operator's Name: DAVID A.WINKLER Service"Technician <br /> Business Name: AFFORDA-TE$T ]CC# 5263373 <br /> Designated Operator's Phone#: 209 744-0112 Ex i ati n Date: 3/27)20 0 <br /> ALTERNATE 2 <br /> Designated Operator's Name: ZANE A. NIMMO Service Technician <br /> Business Name: AFFORDA-TE$T ICC# 5263322 <br /> Designated Operator's Phone#: 209 744-0112 Expiration Date: 3/14/2010 <br /> ALTERNATE. 3 <br /> Designated Operator's Name: FELIX G. RAMIREZ Service Technician <br /> Business Name: AFFORDA-TE$T 1CC# 5273934 <br /> Dcsignated Operator's Phone#: 209744-0112 Expiration Date: 6/21/2010 <br /> 1 certify that, for the facility indicated at the top of this page,the individuals listed above will serve as Designated UST <br /> Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training,in <br /> accordance with California Code of Regulations,title 23,section 2715 (c)-(f). <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br /> ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER (Print): ��f�1$/��J�� IL z- <br /> / C_ <br /> SIGNATURE OF TANK OWNER: <br /> DATE: L// C�l OWNER'S PHONE: <br /> NOTE: <br /> 1)SUBMIT THIS COMPLETED FORM TO THE LOCALAGENCY(NOT STATE WATER RESOURCES CONTROL BOARD) <br /> AFTER SIGNING THE LOCALAGENCY LIST IS AVAILABLE AT: www.waterboards.ca.pov/usUcontact-,Jcupa aevs.html <br /> 2)NOTIJFYTHE LOCALAGENCY OFANYCHANGESTO THIS INFORMATION WITHIN30 DAYS OFTHE CHANCE. <br />