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Nov 25 0910:30a <br />11 <br />#_ r <br />0� <br />209-744-6_ p.1 <br />tip <br />Gait, Ca. 95632 249 744-0113 FAX <br />Owner Statements of Designated Underground Storage Ta r <br />and Understanding of and Compliance with UST Requ 14AL <br />r <br />'`>g7 <br />Facility Name: —{ <br />`l oA 1 W <br />Facility #: <br />Address: <br />ti Cry52` <br />NyeLoa, <br />Reason for this form: <br />I F3 <br />Change of Designated Operator <br />Designated Operator's Phone #: <br />Facility Phone#: <br />',��,0 <br />Update Certificate Expiration Date <br />li 1 ll'' •. �' 1' ,--� <br />Designated Operator's Name: <br />LYLE D. NINMO <br />Senrice Technician <br />Business Name: <br />AFFORDA-TE$T <br />ICC # 5249115 <br />Designated Operator's Phone #: <br />209 744-0112 <br />Expiration Date: v r <br />ALTERNATE 1 <br />Designated Operator's Name. <br />DAVID A. VVE41KLER <br />Service Technician <br />Business Name: <br />AFFORDA-TEST <br />ICC# 5263373 <br />Designated Operator's Phone #: <br />209 744-01 12 <br />i e: 3127 2010 <br />ALTERNATE 2 <br />Designated Operator's Nannie: <br />A. O <br />Service Technician <br />Business Name: <br />AFFORDA-TE$T <br />ICC # 5263322 - <br />Designated Operator's Phone #: <br />209 744-0112 <br />Expiration Date: 3/14120.14 <br />ALTERNATE 3 <br />Designated Operator's Name: <br />FELIX Q RAA9REZ <br />Service Technician <br />Business Name: <br />AFFORDA-TE$T <br />1CC # 5273934 - <br />Designated Operator's Phone #: <br />209744-0112 <br />Expiration Date: 6/21/2010 <br />1 certify that, for the facility indicated at the top of this page, the individuals Fisted above will serve as Designated UST <br />Operators. The individuals will conduct and document monthly facility inspections and annual facility employee training, <br />accordance with Califomia 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 />NAMM OF TANK OWNER (Print): r- T:': _- - k (.: , .I i, ti <br />DATE: <br />. ....... <br />ONVNERIS PHONE: <br />N(YTE: <br />1) SUBMUTM COWLETEDFORM TOT.HELOCALAGENCY(NOTSTATEWATER RESOURCESCONTROLBOARD)AFI'ER <br />SIGNTNQ THE LOCALAGENCY LIST IS AVAILABLE AT' ww-w.waterboards.ca.gov/ust(contacts/cup"gys.html. <br />agys.html. <br />2) NOTIFYTHE LOCALAGENC'YOFANYCHANGESTOTHIS INFORMATION WrMIN 30 DAYS OFTHE CHANGE. 3 <br />