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—Aug. 3. 2010? 6:55AM H Plant Operations (1p) 74 �,,t ,-3'94,$ • P.`2 p. g <br /> Ca 95632 <br /> ffOrd.a-Te t 416 tad Street Phatae:(289)744-01 i FP O <br /> E- <br /> Gatt� Pax.-(2,09)744-016 � 1� <br /> —"�'r°------ eflPorda o�tcom.net 1 � <br /> Owner Statte 1 Onts of]Designated Underground Stora- c Tank <br /> a»d Undemt�anding of and Compliance <br /> with USTRequirementsOperator <br /> k'acility Name: Suttcr Tracy Comrnunity Hvspftal <br /> Address; 4120 N Tracy SlvdTracyCA <br /> Facility Phone#: <br /> Changs:ort) Ied Operator <br /> Q New D"Ipnated Operewr <br /> DE ATED JIST dP g TOR POIt S q,CILTTy�, <br /> PRIMARY <br /> Ixslgnaa:d c�erator's Nmtx: 7,A NE N1mMo <br /> Service TCehrfiolaat <br /> Busi"M Altnte: AFFORDA TEST <br /> JCC Y: 5263322-UC <br /> 1'tcslgnated Oisenttvr's Phony 209.744.0112 Bxomdon Daae; 3/2/12 <br /> ALTERINATE I <br /> Dnignmd Opent-,p Nactte: MAX RAMIftZ Service Technician <br /> ansiness waste: AFFORVA TEST ICC*; 52733934-i✓C <br /> Daaiwimcd for*s Phone: 209.744.0112 <br /> r-.xp`rwdoa Dom: 0112 <br /> ALTEATE <br /> D-igM1100OPMUff'sName: IDAVID WINKLER <br /> SCrvieC TCChniCian <br /> Mmina"Nam,e: AFFORDA TEST <br /> ICC p: 5263373•UC <br /> DC512tatcd Operator's phase_ 209-74"112 Fxpirreian Data: 3/24/12 <br /> ALTERNATE3 <br /> Dfslp►ntsyd Operaroes Name, LYLE NIMmo Scrvlc�Tsshniciar, <br /> AuainessN AFFORDA TEST <br /> [CC il': 52491 15•UC <br /> Desi$ntcd Opet6ror'5 Phone: 209-744-0112 <br /> Iixpirxticm Date: 2l24/12 <br /> 1 certslL that,for Cho lhelllty Indicated at the top of this pAgc,thea IhdividuaI$Ii$Wd above Will acs ve as Designated UST <br /> Actaot ane 1OPMAIM. no ECalilbtn a9Cade of R�u tions,title Mil conduct and nZ3,onthlY sc 1p0 Z7t14 dr one and annual Acitity employoe pining,in <br /> Furthermore,i understand end am in comptiane4 with the requiremeatx 4%tutra,regulations,and local <br /> Ordlnanees) applicable to underground atarogo tsnks, <br /> !NAME OF TANK OWNER(Prlht): 6,��v <br /> SIGNATURE OF TANK OWNER: <br /> DATE; k`► �blo PHONE: ,�1 �. <br /> NO Ts; --� OW � X32 _ <br /> 1) AMOK COMPLOTED FOP-M TO THE LOCM AGENCY(NOTSWKCS)AFTER SIQNMG_7'Ht:1eOCAL AGENCY <br /> IS AVA1t.ABLE A7: v�ww.yatsrtuardx.®y/ust/ ,taabt/eunaht , <br /> 2) NOTIFY THE LOCAL AGENCY GF ANY CIdANOES TO TFi1S INFOR1y <br /> or,F1 ATION WITHIN 30 DAYS OF Tlql4 CHANGE. <br /> TOOln HSPS XVd VZ:VT 60/60 OTOZ <br />