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J <br /> 08/10/2012 14:58 FAX 2097440116 00002/0002 <br /> VAN DE POL Fa'x:20905191'0:. Aug 1-0 P.03. <br /> t r� <br /> �.araity:tFan:: X44.0 <br /> 416 2?d Street Phone°{209)7 12 <br /> x <br /> Owner1 W <br /> Statements of Des ted Underground Storage Tank Operator <br /> d Understanding of and Compliance with.UST Requkements <br /> • <br /> Fa, Name: Fa lity#: <br /> Address: Nse�r i2 LmG(� <br /> ty Phone c /' Q ehsase Dwipated Operator. <br /> p NewDad 04W OPh1AtW , <br /> . N�3"EL US'T E3iP'_ AOR_FQ&=FA s ..,..._,.. :....: . <br /> PREKARY <br /> Dmiguted Op~s Name: 74AM NEYDIO &Miac Technician <br /> Baxweu Name: AFMRDA TEST CC#: <br /> Deftnaud O s Phann =9-744.0112 Facatm 3/7!].4 <br /> . ALTE A7€'E 1 <br /> Nsignaftd Operator's x SeMeMchvidAn <br /> Busiam N=M AFMADA TEST 3CC C <br /> Deftzatctl Opumftes Phomm 2W7"-Ma Expiration M aft 3=4 <br /> AL72RNATE2 <br /> o tot's DAYID W ER T d <br /> Bnsiarss Pismo ORDA; ICC#: UG <br /> Da <br /> kvxW 's.P6obc X944.0113 en s 7,114. <br /> ALTEPWAU.3 <br /> Des tot's L O T <br /> Busine" AMRDA TM C t <br /> Dwgntw OPMWWs Pboar. 21044"In 3=4 <br /> I cartffy jWttfor the•facility indktated at the top of thb: the Individuals.Iis"ted,above,vr0l.am, UST. <br /> The tudividaais' act and Wspetfim and mmug lim My empii►gea <br /> .traluing,in <br /> Accordance with CaWornis C6&of Xquiations,We A eecdon 2715(c)-(4 <br /> FurflmmoM I vad d'w4 in c�)snplishce wif 6c requtremists(ststates,rePlatlow,and ioeai <br /> Ordinanro) appH=ble to mid and aftruge .. € . . . <br /> NA30 OF TANK OWMMt)s <br /> SIGNATUREON=ANK <br /> DATE: <br /> N • <br /> 1) SUBMT TIM COWLEM WMM TO TM LOCAL A (NOT SX(MG.THE LOCAL <br /> AIGXNCY LUT.18 AVANAWA AT:. xW� i�ra�sev eantAct�Cca ati$vs.6tmL . <br /> 2)NOTIMY THE LOCAL NOTAGDFCV OF A1NY • 0 TO THIS WrtM 30 Y9 OF TBE <br /> CEUNGL <br /> county: F iZ, Date ' ► <br />