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Mar 12 08 03: 43p Ffforda Test (2091 744-0116 p . 2 <br /> Owner Statements of Designated Underground Storage Tank(UST) Operator <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Nmc. "� Facility IDD a: <br /> pw.inry Addnet■: �^w tJJ�3} CQ(1�',�n(+, p . Rfor Sabmiaiog dLii Fmn(Owk Om) <br /> Pad Change of Designated Operator <br /> Fardary nmc 0: <br /> Pts aced UST Oor Mtgj(s)for this Facility <br /> "UhLA RY _ <br /> DeiVuftd OpWaw'r Name David A.Winkler Rr,Jgioa w UST Fselltry(CAerk Ow) <br /> Busim"N■a■( ■.tnr above): Affords-Test Service Technician <br /> nmismoW Opwooes rbote r: 209 714-0112 <br /> Imaandonat Coda Gorman ccrdfitation a: 5263373-UC Expin6au Dae: 3/3/08 <br /> ALTERNATE I <br /> Dirmipmod Oper■ma's Name Zane A.Nimmo RAW=to UST Facility(Owck Aw) <br /> auslacm Walla(Q'd y6rs..nr frac■abort): Afford&-Teat <br /> Dodpatod 09'a Ph s: 2 744-0112 Service Technician <br /> tada■ti'.j coat coos l covacs l e: 5263322-UC bTumbm Loa: 2/3/08 <br /> ALTKIWATt 2 <br /> peaigamand Operame.X. Lyle D.Nbamo PA&W a to VST P&ility(Owrk O.K) <br /> Bvsmo N■mt Ufd(Qirr~fres abow): Afferds-Teat <br /> DcASSUM OpardWa raoae a: 209 7444112 Servies Technician <br /> Insvaadmw Com Cantil CartAMeaa It. 5249115-UC Expiratim Data: 7f1/09 <br /> I certify that,far the facility imclicated at the top of this page,the individual(s)listed above will <br /> serve as Designated UST Opennor(s). The individual(s)will conduct and document monthly <br /> facility inspoetiom and annual facility employee training,in accordance with California Code of <br /> Regulations,title 23,section 2715(c) - (f). <br /> Frarthermorc,I understand and am in compliance with the requirements(statutes, . <br /> regulations,and loom ordinances)applicable to underggro�undd Storage tanks. <br /> NAME OF TANK OWNER(t'lease Print): <br /> j l\l l A F�`y���� <br /> SIGNATURE OF TANK OWNER= <br /> DATE:416/4$-- oVVNFR'S,PIIONR 0: <br /> NOTE: 1)SUIIMIT'I'I#IS COMPLETED FORM TO THE LOCAL AGENCY(NOT TLD*STA'L'E WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005-THE LOCAL AGENCY LIST L9 AVAILABLE <br /> AT:wwty watctbOards to IpEL/com■crs/cuoa atrnL <br /> 2)NOTST TIM LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS <br /> OF THE CUANGE. <br /> Novexober 2004 <br /> Z0 39Vd L M3911 WEILZ0 91:60 @00Z/LT/T0 <br /> too LC6G y L-bN 8006/LL/LW <br /> T <br />