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07/30/8010 14;66 FAX 2093683234 GEORGE >iX9RUM INC 11002 <br />Jul 30 SO 10:098 Fiff0da TesT. (2 744-0116 P• 1 <br />Afftorda-Tek <br />416 2"0 Street Phone: (209) 744-0112 <br />Galt, Ca 95632 pax.- (209) 744-0116 <br />atbrda orreaa,.nct SEP <br />Owner Statements of Designated Undergmand Storage Tonk Operator �;1Q <br />and Understanding of and Compliance with UST Requirements 4i <br />Facility NaTmee. Kishida Trucking ra _ <br />Address: 1725 Ackerman DrgLadiCA <br />Facility Mone a., Q Chaftec of Designated Opamtor <br />Q New Deslgmted Operator <br />]D1.5G1`1A'YEA UST OPE <br />S FACILITY: <br />PRIMARY <br />Ruminwge NW0c; <br />AFFORDA TEST <br />De:aignated+Operatar'"Name: <br />ZANE KIA'fMO <br />Service Technician <br />arsines None- <br />AFFORDA TEST <br />ICC M: 5263322-Uc <br />De"ignated Operator's Pham: <br />209-744-0112 <br />Expiration Daea: 3/2/12 <br />ALTERNATE I <br />suol"a" Nam": <br />ARFORDA TEST <br />Raai¢naod OpW=1-6 Name; <br />FELIX RAM IREZ <br />Service Todwivien <br />Business Nunve: <br />AFFORDA TEST <br />ICC M: 52733934 -UC <br />DesI Mated Operator's Phone: <br />209-744-0112 <br />eXpila(ion Date., 4/7112 <br />ALTERNATE 2 <br />D"isnated Oporator'g Name: <br />DAVID WINKLER <br />an <br />Servica Technician <br />Ruminwge NW0c; <br />AFFORDA TEST <br />ice M; 5263371 -UC <br />DesipmIed Operator's Phmc: <br />2OP-744-0112 <br />Explration Date: 3/24/12 <br />ALTERNATE 3 <br />Dewsnated Opaator's Tank. <br />LYLIE NIMMO <br />Service Tvahniclan <br />suol"a" Nam": <br />ARFORDA TEST <br />ICC N: 3249115 -UC <br />De01i$natoel 01grator's Phone <br />209-744.0112 <br />9xpiradon Data: 2/14/12 <br />I art* that, Ibrthe faclllty indicated sit the top of this page. Rho indiVldU613 SSW above wEl1 seava as Deslgaated UST <br />Opemors, The Indtv'duais will conduct and doonmenet monthly fhollity Inspecdan;s acid annual ftlitly emplayea training. In <br />Accordanca With Cslifroritis Caft of Regulations,, titte:23. section n 2715 (c) — (1). <br />Furthermore, I, understand and am In compliance with the requirements (rtatotear reS®iations, and local <br />Ordinances) applicable to underground otorpge tanks. <br />NAMEOFTANKOWNER(Print): —' �'(t-JC" <br />SIGNATURE OP TANK OWNER; <br />DATE: -71 OWNERS PHOXEt <br />NOTE: <br />1) SUBMIT THIS COMPLETSD FORM TO TFIE LACAL A011ONCY (NOT SWRCS) AF'T'ER SIGNING_ THE LOCAL AGENCY <br />LIST IS AVAILABLE AT: www waterheard" na ryy/ earl/co A09 .Ra aovs.bts++l. <br />2) NOTIFY THE I.00AL AGENCY OF ANY CHAN005 TO THIS INFORMATION WITHIN 30 CLAYS OF THE CHANGE. <br />OFFICE: <br />County: Daae Faxed: Pate 6connod: <br />coo z HSI S F Wa LS : ST 60/60 OTOZ <br />