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Kevin Hur <br />48 <br />&"*&% 416 2nd Street Phone: (209) 747"112 1 <br />j�liorda- eat 1 FEB -5 2016 <br />Gait, Ca 9502 Fax: (209) 744-0116 <br />afforda@softcom-net <br />I operator MENTAL <br />Owner Statements of Designated Underground Storage Tank Operator <br />and Understanding of and Compliance with UST Requirements jHFD1TP n=AR"r'A"" <br />Facility Name: Gas Depot Facility #: 1112 P <br />Address: 1330 E Yosemite Avenue Manteca 95M HUpdated owners Sta mens <br />I <br />❑ Change of Designated 0 rator <br />Facility Phone H: a <br />New Designated Ope tOr <br />PRIMARY Service Technician <br />Designated Operator's Name: zANE NIMMO ICC #-. 5263322-U <br />Business Name: AFFORDA TEST <br />Designated operator's Phone: 209-.744-0112. Expiration Date: 2 <br />ALTERNATE <br />Designated Operator's Name: <br />Business Name: <br />Designated Operator's Phone: <br />FELIX RAMIREZ <br />AFFORDA TEST <br />209-744-0112 <br />k— <br />AFFORDA TEST <br />209-744-0112 <br />Service Technician <br />ICC #: 52733934-1 <br />Expiration Date: 3 <br />Service Technician <br />ICC #: 5263373-U <br />Expiration Date: <br />ALTS RNATE 3 Service Technician <br />Business Name: AFFORDA TEST <br />Designated Operator's Name: . EDWARD STEARNS ICC #: 5250492-U, <br />Designated Operator's Phone: 209-744-0112 Expiration Date: <br />I certify that, for the facility indicated at the top of this page, the individuals listed above will serve as Designate <br />Operators. The individuals will conduct and document monthly facility inspections and annual facility emPlo) <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., , I I <br />NAME OF TANK OWNER (Print): <br />F—INVIA <br />UST <br />NOTE: <br />1) SUMMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB) AFTER SIGNING. THE <br />AGENCY LIST IS AVAILABLE AT: www.watcriMard&ga.&2v/uSVCODtaCts/cOVA M56 ml <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF V <br />CHANGE. <br />OFFICE: <br />County- Date Faxed: Date Scanned: <br />Date E -Mailed <br />