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03/30/2012 09:28 FAX IM 0001/0001 <br /> W , <br /> �norda- t 416 2'�Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 MAR 0 2012 <br /> orda@wftcom.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and_Compliance with UST Requirements <br /> Facility Name: r4a-ct- Facility#: 1"I <br /> Address: 3424316'. &'isrn-- R ock.�ov, <br /> Facility Phone#: ❑Change of Designated Operator <br /> 0 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 /> ALTERNATE 1 <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: 312114 <br /> ALTERNATE2 <br /> Designated Operator's Name: DAVID WINICLER Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 312/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AF70RDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <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 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 to <br /> NAME OF TANK OWNER(Print): X tJ A!1n yLiL� <br /> SIGNATURE OF ANI{OWNER: <br /> DATE: Mn,(-�'Y-L--Nf'RSPHONE: <br /> NOTE: <br /> 1) SUBMIT IS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: www.waterboards ca_ u+&ontac 6VA am htmi, <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: [� <br /> County: Bon . ,UL Y, t Date Faxed: 1)L Date Scanned: ,3D f a <br /> 4�3- tx3s <br />