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AN "N"Am-, V <br />416 2nd Street Phone: (209) 744-0112 <br />GaI4 Ca 95632 Fax: (209) 744-0116 MAY 0 8 <br />affords Asofteom.net <br />Facifity N�T��7. fA_r <br />S��)CA\ Facility #: PO# <br />F., To 5 .11417-TTMIFIT, <br />gill, <br />DESIGNATED UST OPE TOR FQR THIS FACILITY: <br />PRIMARY <br />Designated Operator's Name.- ZANENIMMO Service Technician <br />Business Name: AFFORDA TEST ICC M 5263322 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br />ALTERNATE <br />Designated Operator's Name: <br />Business Name: <br />Designated Operator's Phone: <br />ALTERNATE2 <br />Designated Operator's Name: <br />Business Name: <br />Designated Operator's Phone: <br />FELIX RAMIREZ <br />AFFORDA TEST <br />209-744-0112 <br />ALTERNATE3 <br />Designated Operator's Name: LYLENIMMO <br />Business Name: AFFORDA TEST <br />Designated Operator's Phone: 209-744-0112 <br />ALTERNATE 4 <br />Designated Operator's Name: EDWARD STEARNS <br />Business Name: AFFORDA TEST' <br />Designated Operator's Phone; 209-744-0112 <br />Service Technician <br />ICC #: 52733934 -UC <br />Expiration Date: 3/2t14 <br />Service Technician <br />ICC N: 5263373 -UC <br />Expiration Date: 3/2/14 <br />Service Technician <br />[CC #: 5249115 -UC <br />Expiration Date: 3/2/14 <br />Service Technician <br />ICC # 5250492 -UC <br />Expiration Date: 12/29/14 <br />I 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 (Print): rt RE; 7 <br />SIGNATURE OF TANK OWNER: <br />57- 1 - ?,0 J,� <br />DATE: OWNERS PHONE: <br />NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB) AFTER SIGNING. THE LOCAL <br />AGENCY LIST IS AVAILABLE AT: &wLNwaterkQ8Edj.g1.g9v/UsV esm <br />S9ntiicj pa 19yj,htmj- <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />OFFICE. <br />County: Date Faxed: Date Seanned: <br />1ate E -Mailed <br />