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03/30/2012 09:03 FAX a 0001/0001 <br /> h <br /> t. <br /> N.Aug* <br /> OJCCla:-fie � 416 2nd street Phone:(209)744-0112 R <br /> V i Galt,Ca 95632 Fax:(209)744-0116 <br /> afforda oftcom.net <br /> c, <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Facility#' of�?> <br /> ey <br /> Address: 76- W' f l S'' f'r� j• CA-111 3 <br /> Facility Phone#:� 0`;-%) <br /> ) 93Z— 1 p)v El Change of Designated Operator <br /> O El 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: 109-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE I <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: 3/1/14 <br /> ALTERNATE 2 Service Technician <br /> Designated Operator's Name: DAVID WINKLER <br /> Business Name: AFFORDA TEST ICC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> >,,.,ALTERNATE 3 Service Technician <br /> Designated Operator's Name: LYLE NIMMO <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 312/14 <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 fatality inspections and annual facility employee <br /> 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): j8Qzf <br /> SIGNATURE OF TANK OWNER: <br /> DATE: 2-�- 22-L 7 OWNERS PHONE: <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: www w—gIs.ca.aov/ust(contacU enna�• <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. 33 D 2 - <br /> ` A-3�A33 or <br /> 4641-©i3s <br />