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.`Jan 14 08 02:56p R rda Test (2& 744-0116 p.l <br />Owner Statements of Designated Underground Storage Tank (UIENTAL <br />and Understanding of and Compliance with UST Require T 06PA-Rt TMENT <br />F=ility Name: <br />Facility 11) #: <br />Facility Address: <br />Rm%on ror Submitting this Form (Check One) <br />Change of Designated Operator <br />Facility Phone #: <br />Designated UST Onerator(s) for this Facility <br />IJcsipnated Operator's Name: David A. Winkler <br />Relation to UST Facility (Check Our) <br />Service Technician <br />Business Nati (Ifdifferenrfrom nbovc): Afforda-Test <br />Designated operator's Phone #: 209 744-01.12 <br />international Code Council Certification #: 5263373 -UC <br />Expiration Uatc: 3/3/4$ <br />ALTERNATE I aa! <br />flesignated Operator's Ntune: Zane A. Nimmo Relation to LIST Facility ((;heck One) <br />Business Name (!f different from above); -- Afforda-Test <br />Designated operator's Phone #: 209 7-44-0112 Service Technician <br />International Code Council Certification u; 5263322-I1C Expiration Date: 2/3/08 <br />Designated Operator's Name: Lyle 0. Nimmo <br />Relation to UST Facility (Check One) <br />Service Technician <br />Business Name (y4 ferenl from above): A orda-Test <br />Designated operators Phone #: 209 744-0112 <br />International Code Council Certification #: - 5249115 -UC <br />Expiration Date: 7/1/09 <br />I certify that, for the facility indicated at the top of this page, the individual(s) listed above will <br />serve as Designated UST Operator(s). The individual(s) will conduct and document monthly <br />facility inspections and annual facility employee training, in accordance with California Code of <br />Regulations, title 23, section 2715(c) - (f). <br />Furthermore, I understand and am in compliance with the requirements (statutes, <br />regulations, and local ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Please Print): <br />DATE: <br />OWNER'S PHONE #: <br />NOTE: I) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT THE SPATE WATER <br />RESOURCES CON'T'ROL BOARD) BY JANUARY t, 2N5. THE LOCAL AGENCY LIST IS AVAILABLE <br />AT: www.witcrhokr,d.-.;.c.,i.Lov/u%t/et)iiticts/ctip' agys.html., <br />2) NOTIFY THE FOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br />OF THE CHANCE. <br />November 2004 <br />