COMPLIANCE INFO_2002-2012 - Laserfiche WebLink

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Jan 11 1209:53a AFFORDA TEST 0 s.w.,ry 209,744=p1 i6 p.1 JAN a.( Afforda-Te$t 416 2nd Street Galt Ca. 95632 ?aQ 744-0113 209 741 Olt6 F Owner Statements of Designated Underjh4ft&Sthjrage Tank Operator and Understanding of and Compliance with UST Requirements Facility Name: 4 ---- {. Faei " #: Address: tLL ,�� ,�� �tC.)��Y'l1�Un�riY�, L� 1 CA �52�G Reason for this form: Change of Designated Operator Facility Phone 4: ICC # 5249115 ® Update Certificate Expiration Date Designated Operator's Name: LYLE D. N13MO Service Technician Business Name: AFFORDA-TE$T ICC # 5249115 Designated Operator's Phone #: 209 744-0112 Expiration Date: QtcdI r .' UTERNATE. I Designated Operator's Name: DAVEDA.WINKLER Service Technician BusinessName: AFFORDA-TE$T FCC# 5263373 Designated Operator's Phone #: 209744-0112 Ex i tin3/27 010 ALTERNATE 2 uesignated Operator's Name: ZANE A MO Service Technician Business Name: AFFORDA-TE$T FCC # 5263322 - Designated Operator's Phone #: 209 744-0112 Expiration Date: 3/1412010 ALTERNATE 3 Designated Operator's Flame: FELIX Q RAMIREZ Service Technician Business Name: AFFORDA-TE$T 1CC # 5273934- -j)gsignated Operator's Phone 9- ?no 7AA-n t 1,7 6+tit &uOt". VlG F lw',.VLV 1 certify fa in ated a is page, the i als b e e Operat he i i I. f p Mons a an '1 to et i MOMMie with Calif is Code of Regulations, title 23, sec ' n- 5 tc)- Furthermore, )-Furthermore, I understand and am in compli a w' th ui a st egalations, and local ordinances) applicable to underground sto tan NAME OF TANK OWNER (Print):_-�- SIGNATURE OF TANK O R: DATE: �� (: '� '`� OWNER'S PRONE. NOTE: 1) SUBMIT THIS COMPLETED FORM TO THE LOCALAGENCY (NOT STATE WATER RESOURCES CONTROL BOARD) AFTER SIGNING THE LOCAL AGENCY LEST IS AVAILABLE AT: v;ww.waterboards.ca.gov/usdoontacts/Cupa_agys.btmi. 2) NOTIFYTHELOCALAGENC`YOFANYCHANGESTOTHISINFORMATION WITHIN30DAYS OFTHECHANGE. V