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2014-03-11 12:51 TRACY WCK STOP 12048322312 > 2044683433 P 1/1 <br /> 416 e Stract !Phone.(209) 11 <br /> Gait,Co. 2 Fax:(209)7 16RECE1 ED <br /> offordlEaftcom.net <br /> Owner Statements of Designated Underground Tank Operator <br /> and Understand!ng Understandingof and Coma fiance with UST gNuire meats <br /> Facility Name: J' �' Facility M. Poo ftNV1Ht AL <br /> Address: Zc.LkO N Q ,Lm L Upd ted Owners temea <br /> ;-= <br /> Fac' . Phone N: CA-, , 43t S 3ot-Q Ej Chan of Deidpated Operator <br /> azc\ S c_1 d 10 D New I 4Wguated Operator <br /> DESI+GNATED R&T_QLEMTQR MB I= <br /> PRIMARY <br /> Designated Operator's Name: ZANE NIMMO Servi a Technician <br /> Business Name; AFFORDA TMST ICC i ft 5263322-UC <br /> Designated Operator's Phone: 209-7440112 Expli ation Date: 3!3/16 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Sem ce Technician <br /> Business Name: AFFORDA TEST ICC : 52733 LTC <br /> Designated Operator's Phone: 209-744-0112 Expi tion]Date: 3/3/16 <br /> ALTERNATE <br /> Designated Operator's Name: DAVID WINKLER Servk c Technician <br /> Business Names AFFORDA TEST ICC ° 73-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/10/16 <br /> ALTERNATE 3 <br /> Designated Operator's Name: EDWARD STEARNS Servh e Technician <br /> Business Name: AFFORDA TEST ICC : 5250492-UC <br /> Designated Operator's Phone: 209-744-0112 Expij ation Date: 3/3/16 <br /> I certify that,for the facility indicated at the top of this page,the individuals listed above will ser it as Designated UST <br /> Operators. The individuals will conduct and document monthly facility 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 ani in compliance with the requirements(statutes,regulations,a id local <br /> Ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER/Operator(Print): J l f <br /> SIGNATURE OF TANK OWNER/Operator: (�� LD!n4--1 <br /> DATE: v,t k`'2'01 L� OWNERS ONE: 2-. O �' <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT )AFTER Ec IGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT:www.e�aier.�gaetltctl ca.aavinatleontaetAlee�e aeys.html. <br /> 2) NOTIFY THE LOCAI,AGENCY OF ANY CHANGES TO THIS INFORMATION WI'MIN DAYS OF THE <br /> CHANGE. <br /> 0117(1:: <br /> County: 3Dak Fayed: Datc Scanned:�� Date E-Ma led <br />