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Jun 3010 03:49p AFFORDA TEST 209-744-0 p.1 <br /> ILI <br /> Owner Statements of Designated Underground Storage TaAb° %Mor <br /> and Understanding of and Compliance with UST eqtfilUN P <br /> a <br /> Facility Name. C Facility#: h( f�f - ` ,---A Tw <br /> CL Ll� t J ``t oc( <br /> ddress:� `� Reason for this form: <br /> � © Change of Designated Operator <br /> Facility Phone#: Gt S b(� <br /> ��-q 42 -a�`9 0 Update Certificate Expiration Date <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: LYLE D.NIMMO / <br /> Business Name: AFFORDA-TEST <br /> Designated Operator's Phone 9: 209 744-0112 <br /> i <br /> ALTERNATE 1 - <br /> Designated Operator's Name: DAVID A.WINKLER <br /> Business Name: AFFORDA-TE-$T <br /> Designated Operator's Phone 9: 209 744-0 1 1 2 <br /> ALTERNATE 2 <br /> Designated Operator's name: ZANE A. NIMMO <br /> Business Name: AFFORDA-TE$T <br /> Designated Operator's Phone#: 209 744-01 L2 ` <br /> ALTERNATE 3 - <br /> Dek-hated Operator's Name: FELIX G:RAMIREZ Service Technician <br /> Business Name: AFFORDA-TEST [cc 9 5273934-U6 <br /> Designated Operator's Phone#: 209 744-0112 Ex iration;Date: 6/21/2010 <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 training,in <br /> accordance with California Code of Regulations,title 23,section 2715 (c)-(f). <br /> i <br /> Furthermore, I understand and am in compliance with the requirements (statutes, regulations„ and local <br /> ordinances) applicable to underground storage tanks. <br /> i <br /> NAME OF TANK OWlS-ER (Print): ��{ C' �,'�1�%�"a-►-�-�-- <br /> SIGNATURE 4F TANK OVt E �— - =z- -- <br /> DATE: ._�t� 2 , OWNER'S PHONE: ci q g �Xc1 f <br /> 1)SUBMITTHIS COMPLETED FORM TO THE LOCALAGENCY(NOT STATE NATER RESOURCES CONTROLBOARD j <br /> AFTERSIGNING, TETE LOCALAGENCY LIST IS AVAILABLE AT. w,,vw.waterboards.ca.govlust/contacts/cupa agvs.html. <br /> 2)NOTIFYTHE LOCALAGENCY OI!ANY CHANGES TO THIS INFORNIATION WITHIN 30 DAYS OFTHE CHANGE. <br />