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fi&ordLamw e 416 tad Street Phone: (209) 7440112 <br />-TAtGalt, Ca 95632 Fax: (209) 744.0116 <br />a�orda softcana�.rtet <br />Owner Statements of Designated Underground Storage Tank OAN <br />and UndentaRft of and Coln )Iance with UST Requirements <br />Name: Parkwood Gas & Food Faexiity #: 1036-1 <br />Address:1612 M: HammerLane Stockton �' 1 <br />Vmpated Operator <br />o. <br />DFMUST L:_ ; fi:' i1:.. <br />P RJAIARI <br />Aeslgaated+Operatar'si+ me: <br />ZANE NIMMO <br />Business Nate: <br />AFFORDA 'TEST <br />Designated Operator's Phone., <br />209-744-0112 <br />ALTERNATE 1 <br />"- <br />Designated Operator's game: <br />FELIx RAMIREZ <br />Business Name; <br />AIMORDA TEST <br />Designated Operator's Phone: <br />209-7440112 <br />ALTERNATE2 <br />DesignatedOperator's Name: <br />Business Name: <br />Designated Operator's Phone: <br />ALTERNATE3 <br />Designated Operator's Name: <br />B uslness Name: <br />DesignatedOperator's Phone: <br />MATA to i <br />r1ligigg"W1, <br />1 ' k' <br />ii'. Service Technician <br />ICC #: 5263322 -UC <br />Expiration hate: 3/3116 <br />Service Technician <br />ICC #: 52733934 -UC <br />Expiration Date: 313116 <br />Service Technician <br />ICC M. 5263373 -UC <br />Expiration Date: 3/10/16 <br />Service Technician <br />ICC M 5250492 -UC <br />ExpirationDate; U3116 <br />I certify that, for the facility indicated at tate top of this page, the individuals listed above will some as Designated UST <br />Operators. The individuals will conduct and document monthly facility inspections and annual facility employee <br />hraiaing, in <br />Accordance with California Code of Resulations, title 23, section 2715 (g) (1). <br />Fwthormwire, I undmwd &ad am in compliance with *e requirements (statutes, regulaciuns, an�s}a local <br />ap ble m nd storage tanks,`l <br />"; '%' es' 0 t 1, a C ds�Jc� a�a . <br />N OF TANK OWN (F'rint): t r <br />SIGNATURE OF TANK OWNER: <br />DATE: OVMRS PHONE: <br />1) SUMT THIS COMMEM FMM To Ta IAWAL AGgNcv ( joT s) AjnU SIGIM . iU. THE LMA% <br />AGSKY LIST 13 A1'AnABLE AM MMMM <br />2) NOnVY TH111.(ACC,AL AGENCY OF ANY CHANGES TO `rHM INFORMATitIMWYrM30DAVSOVTVR <br />MANGE. <br />Csluitty:,. Date F —1 q Data Scanned; "- <br />Date l �-ly ailed , <br />