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08/10/2012 14:58 FAX 2097440116 <br />VAN DE POL Fex:2094661910 <br />416 tad Street <br />Galt, Ca 95632 <br />Aug 1.4.. 14:0 <br />Phone: (209) 744. <br />Fax: (209)-744.61 <br />t <br />and Understanding of and Compliance with UST Requirements <br />AZ <br />,A.UG'.1 0 ZO11 <br />i <br />Address: V/b <br />Facility Phone #: ❑ Chau o <br />/Yd/✓t! .. ge <br />recces grated Operator. - •.y <br />,. <br />,. I] NeW Da4 <br />nated Operator <br />DESIGNATED UST OPERATOR FOR THUS FACH TT)C: <br />PRIMARY <br />Designated Operator'a Nsmet ZANF NI W40 Service Technician <br />Business Name: AFFORDA TEST - ICC #:5763 <br />UC <br />Designated Operator's PboaC. 70A76/-0112 Expiration D <br />oft: 3M4 .. <br />ALTERNATEi <br />—... <br />Deaigoared Operator's Name:. FELIX RAA'IIItEZ Service Techniciao <br />A <br />-•�. <br />Businew Name! AFFORDA TEST ICC X: 58733 <br />34•UC ' <br />Designated Operator's Pbove: 209-744.0112 Exptration D <br />tte! 3/2/14 <br />ALTERNATE2 <br />Designated Opeettor's Name:..I)AVIM Service Technician <br />Bosieen Name: AFFORDA TEST ICC#: 5263.13-11C <br />Designated operator's Pbona 20444-0112 Expiration <br />te: 312/14 <br />ALTERNATE3 <br />_.... .• <br />Designatedoperator's Name: LYLE NIMMO Service Teebweian <br />'... .. . <br />Business Name: AFFORDA TEST ICC it: 52491 <br />SLC .__.. <br />Designated Openem'sPhone: 209.744-0112 .. Expiration 1) <br />ttc 3/1114 . <br />I certify that, for the faeWiy Indicated at the top of this page, the Individuals listed above will serve <br />Deiignaftd UST <br />Operators. The individuals will conduct and document monthly $lefty inspections and annual fac <br />lity employee , <br />training, in ,.. �.. -:... <br />- ... <br />Accordance with California Code of Regulations, title 23, section 2715 (c)- (f} <br />Furthermore, I anderstzad and am In compliance with the requirements (statutes, regulations, and <br />local ' <br />Ordinances) applicable to underground storage tavlLy y <br />(G A /:'g t fM <br />_ <br />NAME OF TAN©(Print): <br />SIGNATURE OR TANK OWNER- <br />DATIE: B=Ice ' %Z OWNERS PHONE: Ya9- <br />....:.. <br />NOTE:.. <br />1) WBMIT THIS COWLEM FORM TO THE LOCAL. AGENCY(NOT SWRCB) AFTER SI <br />. <br />AG&NCY LI6T I9 AVAILABLE AT:www w o-r_L b� oards.u.ue /use/ to rs!¢ n s btmL <br />2) NOTIFY THE LOCAL AGENCY OF ANY C$ANGE4 TO THIS INFORMATION W1TaxN 30 <br />DAYS OF THE <br />CHANGE. <br />OFFICE: l <br />> Jd Date Faxod: L / U /Z Date Scan <br />County: ,' r' <br />