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A.�fforda—Tv 1 . 416 2nd Street Phone: (209) 744.0112 <br />—_ Gxlt, Ce 95632 Fax; (209) 744-0116 <br />-=—v= =- --�--- afforda of'teom.net <br />Uwner btatemenU of Designated Underground Storage Tank Operator <br />and Understanding of and Compliance with USS' Requirements <br />Facility Name: Rai - '1an `� , Ft $cility #: � h--'1 <br />.Address: V <br />Facility Phone #: ZOpj .: �� � "� �"�' , ❑ Chnupe ofAosignated Operator <br />D XXX ew Designated Oporatnr <br />UES ONA-TED UST OPERAIPM FOR MIS F,A,CILTt'XX: <br />PRIMARY <br />Designatod Operator's Name: <br />yANE NiiroiMD <br />131151nass Name: <br />AFI:'ORDA TEST <br />Designated Oporatnr's Phone: <br />209.744-01 12 <br />ALTERNATE 1 <br />Designated Operator's Name: <br />FELiX RAMIREZ <br />Dnsinmo Name: <br />AFFORDA TEST <br />Designated Operator's Phone: <br />209-744-0112 <br />ALTERNATE 2 <br />DcsignatedOperator'sNamc: <br />DAVID WiKKUR <br />Business Namc: <br />AFFORDA TEST <br />Designatcd Opermor's Phone: <br />209444.0112 <br />ALTERNATE 3 <br />Dagignmcd Operator's Name: <br />JLYLE NIMMO <br />13115inags Name: <br />AFFORDA TEST <br />Desisnated Opcmtor's Phone: <br />2n9-744-0112 <br />Service Technician <br />iCC 9: $253322 -UC <br />Expiration Date: 3/2/12 <br />Service Technician <br />iCC 4: 52733934 -UC <br />Expiration bate: 4/7/12 <br />Service Technician <br />ICC #: 5263373.UC <br />Expiratt'on nate: 3/24/12 <br />Service Technician <br />)CC N. 524911 SAIC <br />Expiration Date: 2/24/12 <br />J certify that, for the facility indicated at the top of this page, the individuals listed above will scree 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, -action 2715 (c) — (f), <br />Furthermore, I understand and am in compliance with the requirements (statutes, regulations, and local <br />Ordinances) applicahle to underground storage tanks, <br />NAME OF TANK OWNER (Print): )� Gi <br />SIGNATURE OF TANK OWNER: —✓t/int r � � <br />DATE: 11/1 /10 OWNERS PHONE -f'9 31 2 0 <br />NOTE: <br />1) SUBMIT THiS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRC8) AFTER SIGNiNG. THE LOCAL AGENCY <br />LiST 1S AVAILABLE AT: jy. wal@rboartls c v jj/ M ' stcunn n�ys.11 j. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF' THE CHANCE, <br />OFFICE. Q <br />Cottnty: �'2r 1 a 1 s't t1 hate faxed: sl,'k,/,o-0i Date Scanned: / " A r'C) <br />