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03/30/2012 09:15 FAX 0 0001/0001 <br /> &Eftj�t 416 2"Street Phone:(209)744-0112 <br /> Galt,Ca 95632 Fax: (209) 744-0116 <br /> affords softcom.net 'MAR 0 2012 <br /> Owner Statements of Designated Underground Storage Tank Operator ".111Jq? i1Jr'4Cp <br /> and Understanding of and Comp fiance with UST Requirementsr�r1�trL'ry <br /> Facility Name: }�; fes, ,� mac,N r, Lam'' �1 Facility_ #: j ' — <br /> Address: I. CA 5D 1�)OCa<I OJC f jAbG� oto � <br /> Facility Phone#: ❑ Change of Designated Operator <br /> 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#: 5263322-UC <br /> Designated Operator's Phone. 209-744-0112 Expiration Date: 312114 <br /> ALTERNATE 1 <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: 3/2/14 <br /> ALTERNATE 2 <br /> Desitrnated Operator's Name: DAVID WINKLER Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5263373-LIC <br /> Designated Operator's Phone: 209-744.0112 Expiration Date: 312114 <br /> ALTERNATES <br /> Designated Operator's Name: LYLE NIMMO Service Technician <br /> Business Name: AFFORDA TEST ICC#: 5249115-UC <br /> Designated Operator's Phone: 209-744-0112 Expiration Date: 3/2/14 <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 training,in <br /> Accordance with Califomia Code of Regulations,title 23,section 2715(c)—(f). <br /> Furthermore,I understand and am in compliance with the requirement totes,regulations,and local <br /> s <br /> Ordinances) applicable to underground storage tanks. 99 <br /> NAME OF TANK OWNER (Print): "11 l�fl' �lf /�G <br /> SIGNATURE OF TANK OWNER; <br /> DATE: -�,-J32 12- OWNERS P": <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.w-aterboards,ca-Mv/ustleontacwcuz)a agys.htrni. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE CHANGE. <br /> OFFICE. \ <br /> County: Date Faxed: 3 /2. Date Scanned: S/ 14 <br /> Le 3433 <br />