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1 <br /> Afforda—Te 416 2"Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 <br /> affords oficom.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Com fiance with UST Requirements <br /> Facility Name; TT (ArFacility#: PO# <br /> ..Address: 3q t k<) tai 4 a-4+\ 'T"A, Updated Owners Statement <br /> Facility Phone#: 1-�ck4 G v 0 Lf Change of Designated Operator <br /> ® New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRMARY " <br /> Designated Operator's Name- 7,ANE NIMMO Service Technician RECEIVED <br /> Business Name: AFFORDA TEST ICC#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2l14 FEB 18-2014 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIM Service TechnicianENVIRONMENTAL HEALTH' <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3!2/14 DEPARTMENT <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: 3/2/14 .. . <br /> ." ALTERNATE 3 <br /> Designated Operator's Name: LYLE NDAMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 31V14 <br /> ALTERNATE4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC# 52SU92•UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 12/29/14 <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 faclifty employ <br /> tralning,lin <br /> Accordatnce with California Code of Regulations,title 23,section 2715(c)—(I). <br /> Furthermore,I understand and am in compliance with the requirements( ,regulations,and local <br /> Ordinances) applicable to underground storage tanks <br /> NAME OF TANK OWNER/Operator(Print): U 14 - -(" S • -,:5tA-rLA <br /> SIGNATURE OF TANK OWNER/Operator: <br /> DATE: OWNERS PHONE: a0 q 2a" c <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.waterboard&0 aov/p, /cgptacts/cuna sevs.wAd. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICE: <br /> County: ' Date Faxed: Date Scanned: 4 � <br /> !. Date E-Mailed i , <br />