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RECEIVED <br /> OCT 03 2013 <br /> 416 2na Street Phone:(209)744-0112 <br /> w Galt,Ca 95632 Fax:(209)744-0116 ENVIRONMENTAL <br /> afforda@softcom.net TMENT <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Sutter Tracy Community Hospital Facility#: <br /> PO# <br /> Address: 1420 N Tracy Blvd Tracy CA 95376 Updated Owners Statement <br /> Facility Phone#:209-832-6032 ❑Change of Designated Operator <br /> Q New Designated Operator <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> PRIMARY <br /> Designated Operator's Name: ZANE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#: 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST FCC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-01I2 Expiration Date: 3/2/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLE NIMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE4 <br /> Designated Operator's Name: EDWARD STEARNS Service Technician <br /> Business Name: AFFORDA TEST ICC# 5250492-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 12/29/14 <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 conduct and document monthly facility inspections and annual facility employee <br /> training,in <br /> Accordance with California Code of Regulations,title 23,section 2715(c)—(f). <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/Operator(Print): <br /> SIGNATURE OF TANK OWNER/Operator: <br /> DATE: 4 !2 }3 _ OWNERS PHONE: `D - 5699�b <br /> NOTE: 1 <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST IS AVAILABLE AT: ,vNvw.waterboards.ca,gov/ust/eontacts&uua aevs.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> CHANGE. <br /> OFFICE: <br /> County: Date Faxed: Date Scanned: <br /> Date E-Mailed <br />