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416 2 d Street Phone:(209)744-0112 <br /> Gait,Ca 95632 j <br /> Fax:(209)744-0116�iftorda-Tet-t <br /> affordaAsoftcom.net <br /> Owner Statements of Designated Underground Storage Tank Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 1\,j1W11k- FQLAS 6LLe Facility#: <br /> r <br /> Address: CA Ln /Y Cd AW p(A %-9-3/6 <br /> :W <br /> 14 <br /> FacilityPhone#: QC�Fj q�?.S il aGel A3.5' 4-J�6� Change of Designated Operator <br /> 3--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 9: 5263322-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date, 3/21141 <br /> ALTERNATEI <br /> Designated Operator's Name: FELIX RAMIREZ Service Technician <br /> Business Name: AFFORDA TEST ICCC 52733934-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 312114 <br /> ALTERNATE 2 <br /> Designated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC 4: 5263373-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> ALTERNATE3 <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ]CC 4: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <br /> 1 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)—(1). <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(Print): I LC- / 10 <br /> I I I 4U Lj <br /> SIGNATURE OF TANK OWNER: <br /> 1-4 <br /> DATE: OWNERS PHONE- 4)4cl 7 <br /> NOTE: <br /> 1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT SWRCB)AFTER SIGNING.THE LOCAL AGENCY <br /> LIST IS AVAILABLE AT: www.watrAgard&ca,ggy/ugfMAQW-opit U.%hUnI- <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE: <br /> County: Date Faxed: Date Scanned: <br />