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08/10/2012 14:39 FAX 2097440116 Q0001/0001 <br /> f �° .®T�i 416 2"Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax:(209)744-0116 AUG 10 2011 <br /> VE"� <br /> afforda softconLuet <br /> Owner Statements of Designated Underground Storage Tank Operator S, t <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: Grupe Commercial Company Facili #: <br /> Address: 5000 S Lindherrgli St Gate 16 Stockton CA 95206 <br /> Facility Phone#: ®Update or D4 signaled Operator <br /> ® New Designs ed Operator <br /> PRIMARY <br /> DESIGNATED UST OPERATOR FOR THIS FACILITY: <br /> Designated Operator's Name; 'LANE NINIA10 Service Technician <br /> Business Name: AFFORDA TEST ICC#: $263322-JC <br /> Designated Operator's phone: 209-744-0112 Expiration Date 3/2/14 <br /> ALTERNATEI <br /> Designated Operator's Nam FELIX RAt'vI IREZ Service Technician <br /> Business Name: AFFORDA TEST ICC#-. 52733934 UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date, 3/2!14 <br /> ALTERNATE 2 <br /> Designated Operator's Nante: DAVID%MNKLER Service Technician <br /> Business Natne: AFFORDA TEST ]CC M. 5263373 <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE 3 <br /> Designated Operator's Nance: LYLE NIMN IO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115- <br /> Designated Operator's Phone: 209-744-0112 Expiration Date. 312/14 <br /> 1 certify that,for the facility indicated at the top of this page,the individuals listed above will serve as D signated 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 locW <br /> applicable underground storage tanks. <br /> NAME OF TANKOR'NER(P �� ( ���� f d 6eM <br /> q, <br /> ff f <br /> SIGNATURE OF TANK OWNER: `{'t'✓ <br /> DATE: Gt �� � f 2-� OWNERS PHONE: Ze)�- 447 -6 Zbq- <br /> NOTE: <br /> 1) SUMMIT THIS COMPLETED FORA TO THE LOCAL AGENCY(NOT S%VRCB)AFTER SIGNING.THE LOCAL <br /> AGENCY LIST ISAVAILABLE AT: uxts.waterbmrds.ea am•/ tactl/ tttat1. <br /> 2) NOTIFY THE LOCAL.AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAY OF THE <br /> CHANGE. <br /> OFFICE-. p t <br /> ECounty: DateFaxed: O Date Scanned: <br /> I <br /> i <br /> i <br /> N <br />