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08/03/2012 16:22 FAX 20974401 (j0001/0001 <br /> fforda- <br /> 4161"Street Phone.(209)744-0112 AUG � <br /> Gait;Ca Fax:(209)74&0116 L � <br /> ofgord n"et <br /> tier statements of Designated Uncle sad Storage Tank Operator <br /> md Understanding of and Complimm with UST Requirements <br /> Facl'h'ty Nanae:Dameron Hoa ital Facility#: <br /> Address: 525 W Acadia St Stockton CA <br /> Faeft' Phone#:209-461-3157 El UpdateafDOWsWOPerstor <br /> D New v <br /> DESIGNA�TFD[Jy TUR]04R MMFACII_ `t`Y• <br /> PRDdARY <br /> Dgugnied tar's Namn ZANE NOINO servicerecluddea <br /> s Nam A TEST ICC#:S= <br /> Operater'sYhaae: 29-744.8118 Date: XV14 <br /> ALTERNATE 1 <br /> DeftatedOperstoftName., FELIXRAbfl= SmiceTcchnician <br /> I <br /> BodnesSNUM AFFORDA TEST ICC#: 53733 C <br /> vesizanted operstorys?how 2099440112 don 4' <br /> ALTERNATE2 <br /> Deshp"W0pftWw,sN=r. DAVEDWINKLER Service Teebaides <br /> Bosiness Name: AFFORDA TEST 1CC#: 3-w <br /> 28994441.12 Ex oats 317114 <br /> ALTERNATE 3 <br /> LYLE NDMO ServiceTechnician <br /> tis : A"ORDA TEST ICC#:SMUS-€1C <br /> X5044-0112 ExAndion Date:;=14 <br /> I for the bdft igdkgftd at the top of this pap,the jodwWWft listed above wM serve as "aced UST <br /> Opwaiom The will conduct and document moathty&d9W WVwUGM sad 880891 faculty`employee <br /> trabdug,in <br /> Accardauce wa CalMorada Code of tions,title A section 2715(c)—(f)- <br /> Farthamore,I understand and am in complhtace with the req ants(OdDim regut and 1001 <br /> to underground tasks. � <br /> N OFT O (Print): �xs <br /> SIGNATURE OF TANK OWNER: <br /> DATE: e /�3t®1.- OWNMS PHONE: 2D4-`tor <br /> NOM. <br /> 1) SEMMTMM COMPLEM FORM TOTM LOCALAG (NOT81CNffft1.TMLOCAL <br /> AGENCY LISTISAV AT:�►vtv»atrr�pQard t[ cues s�sshfml. <br /> 2) NOTHY TM LOCAL AGENCY OFAMY CHANGESTOTM DWOMUTJON WMIN 30 DAYS OFTIIf <br /> OFFICE: $ <br /> County: Date F c2.- Date tied: <br /> 4V3 33 <br /> f <br />