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0 <br />brda- <br />Owner <br />t1416 2� Street <br />` Crap, Ca 95632 <br />11 <br />Phone, (209) 744-0112 <br />Fax: (209) 744-0116 <br />gntated Underground Storage <br />and Compliance with UST Rt <br />CLVED <br />APR 0 7, 014 <br />)NMENTAL HEALTH <br />Facility Name: VDP Ripon Pae ]Pride Facility #: 1300-2 PO# <br />Address: 816 S. Frontage Road ?upon CA 95366 ® Updated Ownera Statement <br />Facility Phone #:209-944.9115 © Change ofDealvated Operator <br />Naw Designated Operator <br />FIESIGNATE� UST OPERATOR FQR THIS FACILITY: <br />PRIMARY Service Technician <br />Designated Operator's Nagle: ZANE NIMMa ICC #: 52b3322 -UC <br />Business Name: AFFORDA TEST Expiration Date: 313!16 <br />Designated Operator's Phone: 209.744-0112 <br />ALTERNATE 1 <br />Designated Operator's Name: FELIXRAMiREZ Service Technicasn <br />Business Name: AFFORDA TEST ICC #: 52733934 -UC <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 313/16 <br />ALTERNATE 2 <br />Designated Operator's Name: DAVID"GVINKLER Service Technician <br />Business Name: ICC TEST ICC #: $263373-UCDate: <br />31X0116 <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3! <br />ALTERNATE3 <br />Designated Operator's Name: EDWARD STEARNS Service Technician <br />Bnsiness Name: AFFO"A. TEST ICC #: ion Dan5049e- 31 <br />Designated Operator's Phone: 209-744-0112 Expiration Date: 3/31X6 <br />1 certify that, far thefseinty indicated at the top of this page, the individuals listed above will serve sa Designated UST <br />Operators. The individuals will conduct and document monthly faeility mspaLems and annual fac0ity employee <br />training, in <br />Aeeordauca with California Code OfRegnlations, title 23, section 2715 (e) -- (f), <br />Furthermore, I understand and tun in compliance With the requirements (statutes, regulations, and local <br />Ordinances) applicable to underground storage tanks. <br />NAME OF TANK OWNER (Print): V /�/ 161161, ��'��'r F '�� <br />SIGNATURE OF TANK OWNVR: " ""` y <br />DATE: 3 / OWNERS PHONE: <br />NOTE: <br />I) S'f1BMIf TRIS COMPLETED FORM TO THE LOCAL AGENCY (NOT SWRCM.4F'rEE SIGNING, THE LOCAL <br />AGENCY LIST IS AVAILABLE AT: www lerhea vl tl h <br />TI NDTIFY TRE LOCAL AGENCY OF ANY CHANGES TO Tins V4FORMATION wT191IN 30 DAYS OF THE <br />CHANGE <br />OFFICE: <br />County,\C Date Faxed: ^"1r Date Scanned: <br />tom` I Date E-Malled <br />0-1 <br />Sav A q,9411/4 <br />