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R J; 1 ". L) <br />fforda-T tt 416 2nd Street Phone: (209) 744-0112 <br />Galt, Ca 95632 Fax: (209) 744-0116 NOV 2 3 015 <br />affords softcom.net <br />Owner Statements of Designated Underground Storage Tank OperatcENVIRONN ENTAL <br />and Understandine of and ComDliance with UST Reauirements HFAITN r1CP40TkAPKIT <br />Facilitv Name: Tovs R Us Facilitv #: 1090-1 PO# <br />Address: 1624 Army Court Stockton CA 95206 ❑ Updated Owners Statement <br />Facility Phone #: 209-4654912 x1418 ❑ Change of Designated Operator <br />® New Designated Operator <br />DESIGNATED UST OPERATOR FOR THIS FACILITY: <br />PRIMARY <br />Designated Operator's Name: LANE NIMMO Service Technician <br />Business Name: AFFORDA TEST ICC #: 5263322 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/16 <br />ALTERNATE] <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: 3/3/16 <br />ALTERNATE 2 <br />Designated Operator's Name: DAVID WINKLER Service Technician <br />Business Name: AFFORDA TEST ICC #: 5263373 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/10/16 <br />ALTERNATE 3 <br />Designated Operator's Name: EDWARD STEARNS Service Technician <br />Business Name: AFFORDA TEST ICC #: 5250492 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/3/16 <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 <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 local <br />Ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER/Operator (Print): T'p�V�/ i¢,tlf — �byj� fZ US <br />SIGNATURE OF TANK OWNER/Operator: <br />DATE: OWNERS PHONE: ZOQ� y6f 4%9� 2 X /SF/p <br />NOTE: <br />1) SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCB) AFTER SIGNING. THE LOCAL <br />AGENCY LIST IS AVAILABLE AT: www.waterboards.ca.e(iv/ust/contacts/cuoa aevs.html. <br />2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br />CHANGE. <br />OFF/CE. <br />County: Date Faxed: Date Scanned: Date E -Mailed <br />