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01/07/2010 10:45 FAX 209 744 0116 )�6- X0001/0002 <br /> ; <br /> VAN DE POL ax:2094661910 Jan 6 9:40 F:iTi <br /> 01/06/2010 10:25 FAX 209 744 0118 0001 <br /> 416 2nd Street Galt,Ca. 95632 209744-0113 209 744- `> <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements., <br /> Fa��tyiva,asg: ® !1 tea.G' tGt r�-r' -e Facey#: <br /> Reason For ttus form. <br /> r j � Change of Designated Oparator <br /> I.Facility * Z �',. t f 1 t�--- ® Update Cec2ificate Expiration Date <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PREWARY <br /> Designated or'sName: LYLED. NIMMO SavicoTechnician <br /> Bussin=Nauss: AFFORDA-TEST ICC# 5249115-UC <br /> Designated Operatar's Phone#: 209744-0112 Expiration Date: Pending <br /> ALTERNATE 1 <br /> Designated Operator's Name: DA A.WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC# 5263373-UC <br /> Designated Operator's phone#: 209744-0112 E /2 1 <br /> ALTERNATE 2 <br /> Designated Operator's Name: ZANE A- NIMMO Service Technician <br /> BusinessName: AFFORDA-TEST ICC# 5263322 UC <br /> Designated Operator's Phone#: 209 744-0 1 1 2 Expiration Date: 3/14/2010 <br /> ALTERNATE 3 <br /> Designated Operator's Name: FELIX G RA?AMZ Service Technician <br /> BusineswsName: ORDA TEST ICC# 5273934-U6 <br /> Desizwded Operator's Phone#: 209744-0112 ExpirationDate: 6/21/2010 <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 cmduct and document monthly facility inspections and asmual facility employee training,in <br /> accordance with California Code of Regulations,title 23,section 2715(c)-(i�. <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):_ EL 0�/..�c.- �f � OF�y �0: /`�G.f <br /> SIGNATURE oFTANI<OWNER: <br /> DATE: — ,( lv OWNER'S ONE: —'�- <br /> NOTR <br /> I)SUBMIT THIS COMPLETED FORMTO TREE LOCALAGENCY(NOT STATE WAT2RRESOURCES CONTROL BOARD)AFTER <br /> SIGNING TIM LOCALAGENCYLISTISAVAMABLEA'C: www•H'a as,gov/usUc0ntactrdcupa_zWs.htrnl. <br /> 2)NOTIFY TM LOCALAGENCY OI'ANY CE ANGES TO THM INFORMATION 30 DAYS OF THE CHANGE <br /> >/17/1,oP,j jjC <br />