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416 2"Street Phone:(209)744-0112 <br /> fforda- <br /> alt,Ca 95632 Fax. (209)744-0116 <br /> jAco. Tt4-1�6-- <br /> affordaCa),softcomnet <br /> Owner Statements of Designated Underground Storage Tank Oper&JWJ /,� <br /> and Understanding of and Compliance with UST Requiremen0 N T <br /> Facility me. ts <br /> il%i M CV- Facility # PO# <br /> Address: a& <br /> updated Owners statement <br /> Facility Phone#: Change of Designated Operator <br /> New Designated Operator <br /> DESIGNATED UST OPEMIQlt FQ&JUja E& <br /> QLITY; <br /> PRIMARY <br /> Designated Operator's Name. ZANE NIMMO Service Technician <br /> Business Name- AFFORDA TEST [CC#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE ] <br /> Designated Operator's Name. FELIXRAMIREZ Service Technician <br /> Business Name: AFFORDA TEST [CC M: 52"133934-UC <br /> Designated Operator's Phone: 209-7744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE <br /> Designated Operator's Name: DAVIDWINKLER ServiceTethnician <br /> Business Name: AFFORDA TEST 1CC#: 5263373-UC <br /> Designated Operator's Phone. 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE <br /> Designated Operator's Name- LYLENIMMO Service Technician <br /> Business Name. AFFORDA TEST ICC#-, 5219115-1 iC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC# 5250492-IIC <br /> Designated Operator's Phone- 209-744-0112 Expiration Date: 12/29/14 <br /> 1 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 facility employee <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. <br /> NAME OF TANK OWNER/Operator(Print): <br /> SIGNATURE OF TANK OWNER/(lperattlr <br /> �tfila <br /> DATE: <br /> OWNERS PHONE: <br /> N0'1'E,-. 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.TIIE LOCAL <br /> AGENCY LIST IS AVAILABLE AT -9Lrb0_atd,,x a,e Lim I <br /> & �fl t—a�'t L 1,! t I <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN M DAYS OF THE <br /> CHANCE. <br /> OFFICE.* qkC Date Scanned: <br /> County* Date Faxed: <br /> ---;j Date E-Mailed <br />