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FEB 22 2012 <br /> 416 2n°Strwa Phone:(109) j <br /> Gait,Ca 95632 Fax:(799)744-01 t6 <br /> afford oflcvin tser <br /> Owner Statmeuts of Designated Underground Storage Tank Operator <br /> and Udderstanding of and Complialact with UST Requirements <br /> Facil-sty Name: `Faei6ty i <br /> Address: t a ,1. Romo n for Form. <br /> Facility Phone#: o?Cs Change of Designated Operator <br /> r--� <br /> t...i Update Cerutieatc EspFrativa Fate <br /> DFMGNATED GST OPERATOR FbR TMS FACILITY: <br /> PRIMARY <br /> DcsizPratedOPc=&m,*sNm= ZANEN1MM0 SmiceTeakician <br /> ausitxss Name: AFFORDA'PEST ICC S. 32633=4X <br /> Omignated Opm tes Phorm 209-744-0172 EbWiration Ddtt::3/7112 <br /> ALTERNATE I <br /> Dcs gmed Opcmtoes Name FELIX RAMtP.EZ ScMccTexhnician <br /> Lnsiness Name! AFFORDA TEST ICC 0: 52733934-M <br /> Dcs icsated Operatoe's Phar: 2D9-74 4-oi 12 <br /> Fxpitatiat Elate: 06112 ' <br /> ALTERNATE2 <br /> Designs Op or^sNa . DAVID E Servim? <br /> ecWdon <br /> ausinen Nara: AFFORDA ICC#-. 5263313-M <br /> Designated Opcmbws thonc: 2D9-744-0112 E%piradon pate: 3124112 <br /> ALTERNATES <br /> Designated Ope un'sNam. LYLE 11IMrAO Service?cchnitian <br /> BusiamNames AFFORDA TEST XCA: 5249115-L`t: <br /> Desigoatcd Operator's P:tonc. 209.'744-0112 E-viri ift Dor- 2,124112 <br /> F certifj'that,for the fk6lity indicated at the top of this page,the indkiduais listed abevc will serve as Designated UST <br /> Operalo rs. The individttais will conduct and do u hent rnonddy faeility inspections sW morass faciiity employcc training.,in <br /> accordance with Catiforrva Code of Rego lations,dtk 23,scctkm 2715(c)—(t). <br /> Furthermore.t understand and'aat in Compiianee with the requirements(statutes,regulations,and local <br /> Ordinances) appiicxble to underground stooge tattles. <br /> tvAIHE OF TANK 0WNER"ntt r"ARA14 J( 7- s ry s N 5,"_/ H U <br /> SIGNATURE oft-TANK OWNER: <br /> DTA '��c;L OVVNE RS PHONE: 4ey '91 <br /> 1) SUS.Vrr THIS COMOLETF22 FORM TO THE LOCAL AGENCY(NOT STA1E WATER RESOURCES C NTR OL SOARD)AFTER <br /> St"ING.THE LOCALAC04CY LIST ES AV#44LA$LEAT: <br /> 2) "G'MY THE LOCA L AC04CY OF ANY CHANCES TO TM INFORMATroN Wn+W 30 DAYS OF THE C14ANGF <br /> TOOO/TOOO[A YEA 6Z:9T ZTOZ/ZZ/ZO <br />