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OI' - a <br /> .. <br /> Aff <br /> !� •416 2°d SU*et Pbone:(209)944-0t7$,. <br /> 41;acl4 Ca 95632 FIN=(249)74"116 �r <br /> afro tanatet <br /> Owner Statements of Designated Underground Storage Ta1r&Operator <br /> and Understanding of and Compliance with USS'Requirements <br /> FFApM— Name: Countgaide,Mini Mart Facility#. 1302 <br /> Address: 14971 N Hwy 88 Lodi CA 95240 FacU ty Phone#:209-368-5380 <br /> erre New Dashp awOpassor <br /> DESIGNATED I=OPTsRATY?R FOR TSPS RAQ.'II.IT <br /> PRITMARY <br /> D-%naW oee= es Na= ZANE X MMO ScMoe Tccb6c= <br /> Business NaenC AFFORDA TEST ICG d: 5263322.UC <br /> PhM= 209-944-0122 E aoDatc 312/12 <br /> ALTERNATE 1 . <br /> �22!!!!2tspho= <br /> Opa:ctx s Nave: FELIX RAS Service Ttcicdam <br /> � AFFORDA TEST' MCA: 52733934-VC <br /> 24*-744-0212 mon Daft;A 7/12 ` <br /> ALTERNATE2 <br /> Op 's Name: DAVID WINICLER Savice Techaiciaa <br /> Business tfa= AFFORDA TEST ICC ti: 5263373-uC <br /> OpeaorPh= 2994OtI24 on Daft 3x412 <br /> ALTIMNATE,3 <br /> a LVIANDdMO Savift TwAlnidw <br /> A TEST ICC k 5249135-UC <br /> Enft!nd OpewcesPhooe•. 209-744-0112 MThadon Do=2JZVI2 <br /> Icwtifyth=,fbrthe&dIftyimdIcated at the top of this pam the individuals listed above will save as Designatod UST <br /> Opaawm Tho indivk aab will canduet and dom=cotmonthly qty inspections and anow facility cmooyw training,is <br /> Accordance with Califbmiac Codc of Regniations,iitIcs 23,sec tioa 2715(c)—(t). <br /> Furtherta Nw,I understand sod am in comptsance with the regaeremeals(slatt+tes,regulations,and local <br /> Ordinances) applicable to underground storage teaks. <br /> TAME OF TAMC OWNER(PrW): <br /> SIGNATURE OF TANK OWNER; �-- <br /> DATE: - �f OWNERS PHONE: ��..5���•�� <br /> NOTE: <br /> 1)SUBA9T T US COh MLETM FOPUM TO MM LOCAL AGBNCY Cgar SWitCB)AnSR SLG Va 771E LOCM.AC.ENCY <br /> LIST IS AVAILABLE A.: vPnm wanrfg,�rvtsss►J�,raets/acea anus <br /> 2)N=WY TME LOCAL.AGENCY OF NYY'CHANGES TO TMS INFOR MOUTTONi wTI IM 30 DAYS OF TkM CHANM <br /> OFFICE <br /> Caaatyc. Date Fixed:ieh q)11 1Dsft Scanned: <br /> ---- ----- VVA en:07 TTOZ/01/90 <br /> y•d <br /> T000/TOOOIA XVd T£:£T TTOZ/tT/90 <br />